Q Mental Health - Substance Abuse Quiz EXAM 2 Combine, Q Substance-Related Disorders Combine, Q Townsend: Unit 5 Combine, **QChapter 14: Substance Use and Addictive Disorders - has ques from test 5 - Combine, **Psych Unit 6 Quizes for Test #2** P, Q...

A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders? 1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. 2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. 3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. 4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not

1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.

Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client? 1. On his or her side, to prevent aspiration 2. In high Fowler's position, to prevent increased intracranial pressure 3. In Trendelenburg's position, to promote blood flow to vital organs 4. In prone position, to prevent airway blockage

1. On his or her side, to prevent aspiration

A morbidly obese client is prescribed an anorexiant medication. The nurse should expect to teach the client about which medication? 1. Phentermine (Mirapront) 2. Dexfenfluramine (Redux) 3. Sibutramine (Meridia) 4. Pemoline (Cylert)

1. Phentermine (Mirapront)

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1. Risk for suicide R/T hopelessness

A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide? 1. The emesis produced during purging is acidic and corrodes the tooth enamel. 2. Purging causes the depletion of dietary calcium. 3. Food is rapidly ingested without proper mastication. 4. Poor dental and oral hygiene leads to dental caries

1. The emesis produced during purging is acidic and corrodes the tooth enamel

16. Order the goals of the levels of prevention as they progress through the public health model set forth by Gerald Caplan. 1. ________ Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness 2. ________ Services aimed at reducing the residual defects that are associated with severe and persistent mental illness 3. ________ Services aimed at reducing the incidence of mental disorders within the population

2, 3, 1

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response? 1. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." 2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." 3. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." 4. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? 1. Altered communication R/T feelings of worthlessness AEB anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered thought processes R/T hopelessness AEB persecutory delusions 4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

2. Social isolation R/T poor self-esteem AEB secluding self in room

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2. Valproic acid (Depakote)

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-lb. weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1.Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2.Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3.Risk for suicide R/T powerlessness AEB insomnia and anorexia 4.Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2.Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? The following are the outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

3, 1, 4, 2

The nurse educator is lecturing a group of nursing students on depression in adolescents. Which statement indicates that teaching has been effective? 1. "Adolescents are not likely to suffer from depression." 2. "Depressed adolescents always seek immediate treatment." 3. "Many symptoms are attributed to normal adjustments of adolescents." 4. "Suicide is not common among depressed adolescents."

3. "Many symptoms are attributed to normal adjustments of adolescents."

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

3. "Weight gain is a common, but troubling, side effect."

A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal 2. Conducting 15-minute checks to ensure safety 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations 4. Encouraging client to express feelings related to suicide

3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? 1. The client gained two pounds in one week. 2. The client focused conversations on nutritious food. 3. The client demonstrated healthy coping mechanisms that decreased anxiety. 4. The client verbalized an understanding of the etiology of the disorder

3. The client demonstrated healthy coping mechanisms that decreased anxiety.

A client's altered body image is evidenced by claims of "feeling fat," even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? 1. The client will consume adequate calories to sustain normal weight. 2. The client will cease strenuous exercise programs. 3. The client will perceive personal ideal body weight and shape as normal. 4. The client will not express a preoccupation with food.

3. The client will perceive personal ideal body weight and shape as normal.

A nurse administers 100 percent oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? 1. To prevent increased intracranial pressure resulting from anoxia 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation 3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles 4. To prevent blocked airway, resulting from seizure activity

3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder? 1. "Skaters need to be thin to improve their daily performance." 2. "All the skaters on the team are following an approved 1200-calorie diet." 3. "The exercise of skating reduces my appetite but improves my energy level." 4. "I am angry at my mother. I can only get her approval when I win competitions."

4. "I am angry at my mother. I can only get her approval when I win competitions."

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, "My parents watch me like a hawk and never let me out of their sight." Which nursing diagnosis would take priority at this time? 1. Altered nutrition less than body requirements 2. Altered social interaction 3. Impaired verbal communication 4. Altered family processes

4. Altered family processes

A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis? 1. The client is disheveled and malodorous. 2. The client refuses to interact with others and isolates self in room. 3. The client is unable to feel any pleasure. 4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

When planning care for a depressed client, which correctly written outcome should be a nurse's first priority? 1. The client will promise not to physically harm self. 2. The client will discuss feelings with staff and family by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will remain safe during hospital stay.

4. The client will remain safe during hospital stay.

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

4."Agitated and pacing. Exhibiting grandiosity. Mood labile."

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1.Symptoms indicate consumption of foods high in tyramine. 2.Symptoms indicate lithium carbonate discontinuation syndrome. 3.Symptoms indicate the development of lithium carbonate tolerance. 4.Symptoms indicate lithium carbonate toxicity.

4.Symptoms indicate lithium carbonate toxicity.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to Alcoholics Anonymous (AA), would be most appropriate for a nurse to discuss with the client during discharge teaching? Select one: a. After discharge, the client will immediately attend 90 AA meetings in 90 days. b. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. c. After discharge, the client will incorporate family in AA attendance. d. After discharge, the client will seek appropriate deterrent medications through AA.

A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? a. Risk for injury R/T central nervous system stimulation. b. Disturbed thought processes R/T tactile hallucinations. c. Ineffective coping R/T powerlessness over alcohol use. d. Ineffective denial R/T continued alcohol use despite negative consequences

A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

15. Which of the following have been assessed as the most common types of mental illness identified among homeless individuals? (Select all that apply.)A. Schizophrenia B. Body dysmorphic disorder C. Antisocial personality disorder D. Neurocognitive disorder E. Conversion disorder

A, C, D

4. A client at the mental health clinic tells the case manager, "I can't think about living another day, but don't tell anyone about the way I feel. I know you are obligated to protect my confidentiality." Which case manager response is most appropriate? A. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care. "B. "Let's discuss steps that will resolve negative lifestyle choices that may have increased your suicidal risk. "C. "You seem to be preoccupied with self. You should concentrate on hope for the future. "D. "This information is secure with me because of client confidentiality."

A. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care.

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

ANS: 1 Page: 427-430 Feedback 1 The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt. 2 Anxiety: severe R/T hyperactivity does not address the client's risk for suicide. 3 Imbalanced nutrition: less than body requirements R/T refusal to eat does not address the client's risk for suicide. 4 Dysfunctional grieving R/T loss of employment does not address the client's risk for suicide.

ANS: 4 Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

ANS: 1 Rationale: The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure.

A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? 1. Psychological addiction 2. Physical addiction 3. Substance induced disorder 4. Social induced disorder

ANS: 1 Rationale: The nurse should use the term psychological addiction to best describe the client's situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? 1. Risk for injury R/T central nervous system stimulation 2. Disturbed thought processes R/T tactile hallucinations 3. Ineffective coping R/T powerlessness over alcohol use 4. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: 1 Rationale: The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

2. A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-lb. weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

ANS: 2 Page: 419-422 Feedback 1 Knowledge deficit R/T bipolar disorder AEB concern about symptoms does not identify the client's sudden 12-lb. weight loss. 2 The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health. 3 Risk for suicide R/T powerlessness AEB insomnia and anorexia does not identify the client's sudden 12-lb. weight loss. 4 Altered sleep patterns R/T mania AEB insomnia for the past 3 nights does not identify the client's sudden 12-lb. weight loss.

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

ANS: 2 Page: 435-438 Feedback 1 Sertraline (Zoloft) does not counteract the weight-increasing effects of lithium. 2 The nurse should anticipate that the physician may prescribe valproic acid in order to increase this client's medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss. 3 Trazodone (Desyrel) does not counteract the weight increasing effects of lithium. 4 Paroxetine (Paxil) does not counteract the weight increasing effects of lithium.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction? 1. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

ANS: 2 Rationale: The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse's first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration

ANS: 2 Rationale: The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use.

3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? The following are the outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

ANS: 3 Page: 419-422 Feedback 1 The client's safety and physical health is the most important. 2 Safety is the priority. 3 The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's safety and physical health as most important 4 The nurse should always prioritize safety.

7. A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

ANS: 3 Page: 427 Feedback 1 Weight loss is not typical with this drug. 2 Clients gain weight regardless of diet with Lithium therapy. 3 The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication. 4 Weight gain is a common side effect with this medication.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? 1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: 3 Rationale: The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

1. A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

ANS: 4 Page: 419-422 Feedback 1 Exhibiting looseness of association and being euphoric is not associated with bipolar disorder. 2 Magical thinking is not associated with bipolar disorder. 3 Labile mood and delusions of reference are not associated with bipolar disorder. 4 The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one's abilities are better than everyone else's.

8. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

ANS: 4 Page: 434, 439 Feedback 1 These symptoms do not indicate consumption of foods high in tyramine. 2 These symptoms do not indicate lithium carbonate discontinuation syndrome. 3 These symptoms do not indicate development of lithium carbonate tolerance. 4 The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly with maintenance therapy to ensure proper dosage.

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

ANS: 4 Page: 435-438 Feedback 1 Zyprexa calms hyperactivity. 2 Zyprexa does not prevent extrapyramidal side effects. 3 Zyprexa does not increase the effectiveness of the immune system. 4 The nurse should explain to the client's spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder.

Which client statement indicates a knowledge deficit related to a substance use disorder? 1. "Although it's legal, alcohol is one of the most widely abused drugs in our society." 2. "Tolerance to heroin develops quickly." 3. "Flashbacks from LSD use may reoccur spontaneously." 4. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: 4 Rationale: The nurse should determine that the client has a knowledge deficit related to substance use disorders when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal? 1. Antagonist therapy 2. Deterrent therapy 3. Codependency therapy 4. Substitution therapy

ANS: 4 Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. The individual is experiencing psychological dependency. B. The individual is experiencing physical dependency. C. The individual is experiencing substance dependency. D. The individual is experiencing social dependency.

ANS: A The nurse should use the term "psychological dependency" to best describe this client's situation. A client is considered to be psychologically dependent on a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

6. What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessened the client's response to another drug.

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

ANS: B The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder.

8. A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimer's disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this client's symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

ANS: C Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing which is followed by inappropriate compensatory behaviors.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

7. A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

3. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

Which client statement indicates a knowledge deficit related to substance abuse? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society." B. "Tolerance to heroin develops quickly." C. "Flashbacks from LSD use may reoccur spontaneously." D. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder? A. "Skaters need to be thin to improve their daily performance." B. "All the skaters on the team are following an approved 1,200-calorie diet." C. "When I lose skating competitions, I also lose my appetite." D. "I am angry at my mother. I can only get her approval when I win competitions."

ANS: D This client statement reflects the underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family member's development of anorexia nervosa.

Dan, who has been admitted to the alcohol rehab unit after being fired for "drinking on the job", states "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my co-workers." The defense mechanism that Dan is using is: A) Denial B) Projection C) Displacement D) Rationalization

ANSWER: A A) Denial

Mr. White is admitted to the hospital after and extended period of binge alcohol drinking. His wife reports that he has been a heavy drinker for a number of years. Lab reports reveal he has a blood alcohol level of 250mg/dL. He is placed on a chemical dependency unit for detoxification. When would the 1st signs of alcohol withdrawal symptoms be expected to occur? A) Several hours after the last drink B) 2-3 days after the last drink C) 4-5 days after the last drink D) 6-7 hours after the last drink

ANSWER: A A) Several hours after the last drink

Dan begins attendance at AA meetings. Which of the statements by Dan reflects the purpose of this organization? A) "They claim they will help me stay sober" B) "I'll dry out, in AA, then I can have a social drink now and then." C) "AA is only for people who have reached the bottom." D) "If I loose my job, AA will help me find another one"

ANSWER: A A) "They claim they will help me stay sober" What Is A.A.? Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem. It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere. There are no age or education requirements. Membership is open to anyone who wants to do something about his or her drinking problem.

Dan, who has been admitted to the alcohol rehab unit after being fired for "drinking on the job", states "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my co-workers." The nurses best response is: A) "Maybe you boss is mistaken, Dan." B) "You are here because your drinking was interfering with your work, Dan" C) "Get real, Dan! You're a boozer and you know it" D) "Why do you think your boss sent you here, Dan'?

ANSWER: B B)" You are here because your drinking was interfering with your work, Dan"

Which of the following medications is the physician most likely to order for the client experiencing alcohol withdrawal syndrome? A) Haloperidol (Haldol) B) Chlordiazepoxide (Librium) C) Methadone (Dolophine) D) Phenytoin (Dilantin)

ANSWER: B B) Chlordiazepoxide (Librium) Treats anxiety, symptoms of alcohol withdrawal, and tremor. This medicine is a benzodiazepine. Side effects -Depressed mood or severe confusion, Extreme unsteadiness (trouble standing), Severe drowsiness and weakness, Slow heartbeat, Sudden mood changes, Trouble breathing, Blurred vision, headache, Diarrhea or constipation, Drowsiness, dizziness, clumsiness, Dry mouth, upset stomach, Feeling "hungover" the next morning after bedtime use, Trouble concentrating Legal status: Schedule II controlled substance, Schedule IV controlled substance Drug class: Benzodiazepine Other drugs in same class: Diazepam, Alprazolam, Lorazepam, May treat: Alcoholism, Anxiety disorder

Symptoms of alcohol withdrawal include: A) Euphoria, hyperactivity, and insomnia B) Depression, suicidal ideation, and hypersomnia C) Diaphoresis, n/v, and tremors D) Unsteady gait, nystagmus, and profound disorientation

ANSWER: C C) Diaphoresis, n/v, and tremors

Dan, who has been admitted to the alcohol rehab unit after being fired for drinking on the job. Dan's drinking buddies come for a visit, and when they leave, the nurse smells alcohol on Dan's breath. Which of the following would be the best intervention with Dan at this time? A) Search his room for evidence. B) Ask, " Have you been drinking alcohol, Dan?" C) Send a urine specimen from Dan to the lab for a drug screening. D) Tell Dan, "These guys cannot come to the unit to visit you again".

ANSWER: C C) Send a urine specimen from Dan to the lab for a drug screening.

The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should: Apply a tourniquet to the client's arm Administer an anticonvulsant medication Ask the client if he is allergic to shellfish Apply a blood pressure cuff to the arm

Apply a blood pressure cuff to the arm applied to the client's arm prior to the initiation of ECT

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? Select one: a. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. b. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. c. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. d. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

14. Which of the following are characteristics of a Program of Assertive Community Treatment (PACT), as described by the National Alliance on Mental Illness (NAMI)? (Select all that apply.)A. PACT offers nationally based treatment to people with serious and persistent mental illnesses. B. PACT is a type of case-management program. C. The PACT team provides services 24 hours a day, 7 days a wk, 365 dys a year. D. The PACT team provides highly individualized services directly to consumers. E. PACT is a multidisciplinary team approach.

B, C, D, E

13. Which of the following clients should a nurse recommend for a structured day program? (Select all that apply.) A. An acutely suicidal teenager B. A chronically mentally ill woman who has a history of medication non-adherence C. A socially isolated older individual D. A depressed individual who is able to contract for safety E. A client who is hearing voices that tell the client to harm others

B, E

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? Select one: a. "Why do you assume responsibility for his behaviors?" b. "Codependency is a typical behavior of spouses of alcoholics." c. "Your husband needs to deal with the consequences of his drinking." d. "Do you understand what the term enabler means?"

C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

Upon admission to an inpatient treatment facility for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? Select one: a. Knowledge deficit b. Fluid volume excess c. Imbalanced nutrition: less than body requirements d. Ineffective individual coping

C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

7. A newly admitted homeless client diagnosed with schizophrenia states, "I have been living in a cardboard box for two weeks. Why did the government let me down?" Which is an appropriate nursing response? A. "Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless. "B. "Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia. C. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success.

C. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success.

1. A nursing instructor is teaching about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act? A. Many perspective clients did not meet criteria for mental illness diagnostic-related groups. B. Zoning laws discouraged the development of community mental health centers. C. States could not match federal funds to establish community mental health centers. D. There was not a sufficient employment pool to staff community mental health centers.

C. States could not match federal funds to establish community mental health centers.

Which client statement indicates a knowledge deficit related to substance abuse? Select one: a. "Although it's legal, alcohol is one of the most widely abused drugs in our society." b. "Tolerance to heroin develops quickly." c. "Flashbacks from LSD use may reoccur spontaneously." d. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? Select one: a. To assess for emotional strength. b. To assess for Wernicke-Korsakoff syndrome. c. To assess for tachycardia. d. To assess for fine tremors.

D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

5. When intervening with a married couple experiencing relationship discord, which nursing action reflects an intervention at the secondary level of prevention? A. Teaching assertiveness skills in order to meet assessed needs B. Supplying the couple with guidelines related to marital seminar leadership C. Teaching the couple about various methods of birth control D. Counseling the couple related to open and honest communication skills

D. Counseling the couple related to open and honest communication skills

An appropriate nursing intervention for the client with borderline personality disorder is: Observing the client for signs of depression or suicidal thinking Allowing the client to lead unit group sessions Restricting the client's activity to the assigned unit of care throughout hospitalization Allowing the client to select a primary caregiver

a Observing the client for signs of depression or suicidal thinking

A client with a history of schizophrenia is seen in the local health clinic for medication follow-up. To maintain a therapeutic level of medication, the nurse should tell the client to avoid: Taking over-the-counter allergy medication Eating cheese and pickled foods Eating salty foods Taking over-the-counter pain relievers

a Taking over-the-counter allergy medication

A nurse is assessing a client diagnosed with paranoid schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of "making observations?" a. "I notice that you are talking to someone who I do not see." b. "Please tell me what they are telling you." c. Why do you continually look up at the ceiling?" d. I understand that you see someone in the hall, but I do not see anyone."

a. "I notice that you are talking to someone who I do not see." Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse's perceptions.

The client with schizophrenia is preparing for discharge. To minimize relapse, what is the most important feature of planning the client's aftercare? a. An accurate description of the medication regimen with a specific plan for obtaining refills b. Identification of three new methods of spending leisure time c. Ensuring that the client lists three potential sources of social support d. Identification of two new ways to bolster self-esteem

a. An accurate description of the medication regimen with a specific plan for obtaining refills The nurse should recognize that the most common reason patient's relapse or decompensate into their illness is because they have stopped taking their medication, so teaching should emphasize compliance with medication.

A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? a. Sore throat, fever, and malaise b. Akathesia and hypersalivation c. Akinesia and insomnia d. Dry mouth and urinary retention

a. Sore throat, fever, and malaise Intervene immediately if client experiences signs of infectious process-such as sore throat, fever, & malaise-when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection.

The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: Agnosia Apraxia Anomia Aphasia

b Apraxia

A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 mEq/L. What behavior changes would be most common for this client? a Anger b Mania c Depression d Psychosis

b Mania

A client with schizophrenia has become disruptive and requires seclusion to help him regain control of his behavior. Which staff member can institute seclusion? a The security guard b The registered nurse c The licensed practical nurse d The nursing assistant

b The registered nurse

Which of the following client statements would demonstrate a major symptom of schizophrenia spectrum disorder? a. "I've been depressed ever since our house was destroyed by fire." b. "You can read my mind. This light of mine will shine, fine; blinding world will end at nine." c. "I had too much to drink last night, started feeling all-powerful, and stupidly drove my truck into a tree." d. ''A stitch in time saves nine' means that prevention is easier than fixing a real problem."

b. "You can read my mind. This light of mine will shine, fine; blinding world will end at nine." The nurse should recognize this statement is a rhyming statement and is called a clang association and is a positive symptom of schizophrenia spectrum disorder.

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? a. Establishing personal contact with family members. b. Being reliable, honest, and consistent during interactions. c. Sharing limited personal information. d. Sitting close to the client to establish rapport.

b. Being reliable, honest, and consistent during interactions. The nurse can enhance the establishmt of a trusting relationship w/a client diagnosed w/schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in: One week Two weeks Four weeks Six weeks

c Four weeks

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? a. Haloperidol (Haldol) to address the negative symptom. b. Clonazepam (Klonopin) to address the positive symptom. c. Risperidone (Risperdal) to address the positive symptom. d. Clozapine (Clozaril) to address the negative symptom.

c. Risperidone (Risperdal) to address the positive symptom. The nurse should recognize that appearing to listen to unseen others is an example of experiencing an auditory hallucination which is a positive symptom of the illness and Risperidone is an antipsychotic medication for this purpose.

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize? a. Respirations of 22 beats/minute b. Weight gain of 8 pounds in 2 months c. Temperature of 106 degrees F d. Excessive salivation

c. Temperature of 106 degrees F high temperature could be an indicator of neuroleptic malignant syndrome (NMS), a serious and potentially fatal side effect of anti-psychotic medication, notify HCP immed.

A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, "I don't know why you are all so worried; I am in control. I don't have a problem." Which defense mechanism is being utilized? Rationalization Projection Dissociation Denial

d Denial

How can the nurse assist a newly admitted schizophrenic client to become comfortable initially, on the psychiatric unit? a. Assign him a unit responsibility. b. Allow him to stay in his room the first few days. c. Put him group therapy and introduce him to others. d. Allow him to move at his own pace.

d. Allow him to move at his own pace. The nurse should recognize that the new environment could promote fear and discomfort to this client, so allowing him to move at their own pace and not to force them into any situation that may be uncomfortable for them, will help in developing a trusting nurse-client relationship.