317 Exam #4

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?

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

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? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

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

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?

"FIND" tool

A client's spouse asks, "What evidence supports the possibility of genetic transmission of bipolar disorder?" Which is the best nursing reply?

"Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder."

Which client statement indicates to the nurse that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. "I will limit my intake of fluids daily." B. "I will maintain normal salt intake." C. "I will take Lithobid on an empty stomach." D. "I will increase my caloric intake to prevent weight loss."

"I will maintain normal salt intake."

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

"I will maintain normal salt intake."

The mental health nurse is providing discharge teaching for a client diagnosed with Bipolar Disorder. Which statement indicates that the nurse's teaching is effective? A. "I shouldn't take my lithium when I have the flu." B. "I am looking forward to having real coffee in the morning." C. "I can get off medication in 5 years if I am stable." D. "I'll be the designated driver since I shouldn't have alcohol with lamotrigine."

"I'll be the designated driver since I shouldn't have alcohol with lamotrigine."

After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement?

"I'll call my doctor immediately if I experience any diarrhea or ringing in my ears."

After teaching a client about lithium carbonate (Lithane), the nurse would conclude teaching was successful based on which client statement? A. "I should expect to feel better in a couple of days." B. "I'll call my doctor immediately if I experience any diarrhea or ringing in my ears." C. "If I forget a dose, I can double the dose the next time I take this drug." D. "I need to restrict my intake of any food containing salt."

"I'll call my doctor immediately if I experience any diarrhea or ringing in my ears."

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom?

"I'm the world's most perceptive attorney."

The nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement provides supportive evidence of this symptom? A. "I can't stop my sexual urges. They have led me to numerous affairs." B. "I'm the world's most perceptive attorney." C. "My wife is distraught about my overspending." D. "The FBI is out to get me."

"I'm the world's most perceptive attorney."

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?

"This disorder is more prevalent in the higher socioeconomic groups."

Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of a: A. Delusion of persecution B. Delusion of reference C. Delusion of control or influence D. Delusion of grandeur

A. Delusion of persecution

A client diagnosed with schizophrenia experiences identify confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? A. identify with the person speaking B. imitate the nurse's movements C. alleviate alogia D. alleviate avolition

A. identify with the person speaking Echolalia is a parrot-like repetition of overheard words or fragments of speech. it is an attempt by the client to identify with the person who is speaking.

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Expressions of poor self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Depressed clients do not care enough about themselves to participate in grooming and hygiene.

A nurse is caring for four clients taking various medications including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving monoamine oxidase inhibitor (MAOI) who consume foods or drugs high in tyramine content.

Which carries a warning label stating that the use of the medication increases risk for suicidal thoughts and behaviors? A. Antipsychotics B. Antiepileptics C. Mood stabilizers D. Anxiolytics

Anxiolytics

A client is being discharged on haloperidol (Haldol). Which teaching should the nurse include about the medication? A. "If you forget to take your morning dose of Haldol, double the dose at bedtime." B. "Limit your alcohol intake to no more than 3 ounces per day. " C. "When you go home, sit outside and enjoy the sunshine." D. "Do not stop taking Haldol abruptly."

D. "Do not stop taking Haldol abruptly." The client should be taught not to stop taking Haldol abruptly after long-term use. To do so might produce withdrawal symptoms, such as N/V, dizziness, gastritis, headache, tachycardia, insomnia and/or tremulousness

A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess?

Flight of ideas

As clients are leaving the dayroom following a group therapy session, the nurse notices a client admitted for acute mania is clenching and unclenching both fists, swearing, and glaring at a staff member. Which action should the nurse take first? A. Calmly ask the client to go to the "quiet room." B. Instruct clients to return to the dayroom. C. Prepare to administer a sedative medication. D. Ask a staff member to call hospital security.

Instruct clients to return to the dayroom.

A client who has been diagnosed with Bipolar I Disorder states, "God has taught me how to decode the Bible." The nurse should anticipate which combination of medications would be ordered to address this client's symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal)

Lithium carbonate (Lithobid) and risperidone (Risperdal)

A client diagnosed with Bipolar Disorder: Depressive Episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. Which should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment

Risk for suicide R/T hopelessness

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?

Risk for suicide R/T hopelessness

A client is diagnosed with Bipolar Disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.

The client will remain safe throughout hospitalization.

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?

The client will remain safe throughout hospitalization.

An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order?

This dosage is more than twice the recommended dosage range.

A client with bulimia nervosa is scheduled for a visit to the clinic. When assessing this client, which of the following would the nurse expect to find? A) impulsivity B) panic C) hyperactivity D) delusions

a

A client's spouse asks, "What evidence supports the possibility of genetic transmission of bipolar disorder?" Which is the best nursing reply? A. "Clients diagnosed with Bipolar Disorders have alterations in neurochemicals that affect behaviors." B. "Higher rates of relatives diagnosed with Bipolar Disorder are found in families of clients diagnosed with this disorder." C. "Higher rates of relatives of clients diagnosed with Bipolar Disorder respond in an exaggerated way to daily stress." D. "More individuals diagnosed with Bipolar Disorder come from higher socioeconomic and educational backgrounds."

"Higher rates of relatives diagnosed with Bipolar Disorder are found in families of clients diagnosed with this disorder."

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates learning has occurred? A. "This disorder is more prevalent in lower socioeconomic groups." B. "This disorder is more prevalent in higher socioeconomic groups." C. "This disorder is equally prevalent in all socioeconomic groups." D. "This disorder's prevalence cannot be evaluated on the basis of socioeconomic groups."

"This disorder is more prevalent in higher socioeconomic groups."

An adult client diagnosed with Bipolar I Disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which statement about this medication order is true? A. "This dosage is within the recommended dosage range." B. "This dosage is lower than the recommended dosage range." C. "This dosage is more than twice the recommended dosage range." D. "This dosage is four times higher than the recommended dosage range."

"This dosage is more than twice the recommended dosage range."

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with Bipolar Disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. "Treatment is compromised when clients can't sleep." B. "Treatment is compromised when irritability interferes with social interactions." C. "Treatment is compromised when clients have no insight into their problems." D. "Treatment is compromised when clients choose not to take their medications."

"Treatment is compromised when clients choose not to take their medications."

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?

"Treatment is compromised when clients choose not to take their medications."

A client began taking lithium 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 reply?

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

A client began taking lithium 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 reply? A. "That's strange. Weight loss is the typical pattern." B. "What have you been eating? Weight gain is not usually associated with lithium." C. "Weight gain is a common but troubling side effect." D. "Weight gain occurs only during the first month of treatment with this drug."

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

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 questions the Zyprexa order. Which is the appropriate nursing reply? A. "Zyprexa in combination with Eskalith cures manic symptoms." B. "Zyprexa prevents extrapyramidal side effects." C. "Zyprexa ensures a good night's sleep." D. "Zyprexa calms hyperactivity until the Eskalith takes effect."

"Zyprexa calms hyperactivity until the Eskalith takes effect."

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 questions the Zyprexa order. Which is the appropriate nursing reply?

"Zyprexa calms hyperactivity until the Eskalith takes effect."

A client is experiencing extrapyramidal symptoms secondary to neuroleptic drug therapy. The physician ordered biperiden (Akineton), 2mg tid IV. If a 5mg/mL vial is used, what is the total amount, in mL per day, that the nurse will administer?

1.2

A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level?

1.7 mEq/L

A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L

1.7 mEq/L

A psychiatric​mental health nurse working in the community is planning an educational program for fifth and sixth grade teachers. Which of the following would the nurse include? A) Discussion of strategies the teachers can use to counteract the role media plays in encouraging eating disorders B) Emphasis on the need for teachers to focus their prevention efforts on female students C) Stressing of the need to allow students to eat without undue attention or supervision to prevent inadvertently influencing eating patterns D) Clarification that peer pressure is not typically problematic in children who are in the fifth and sixth grades

A

While caring for a client with anorexia nervosa, the nurse anticipates that the client would have difficulty making which of the following comments? A) ​I'm mad at you because you won't let me go on a pass unless I gain weight!​ B) ​I need to have everything in its place and perfect.​ C) ​If I gain a pound, I'll just keep gaining weight.​ D) ​​I am very involved in preparing my food and counting calories.​

A

The family of a patient who has been prescribed antipsychotic medication tells the nurse they understand there are potentially fatal side effects with these medications. They ask the nurse for information about what they should look for that could signal potentially dangerous or fatal side effects. Which of the following responses by the nurse are accurate with regard to the family's question? (Select all that apply) A. "If the patient has acute muscle spasms or the patient's eyes appear to be rolling back, emergency intervention should be sought." B. "if the patient has an unusually high fever and complains of muscle rigidity, any further antipsychotic medication should be discontinued and immediate emergency intervention should be sought." C. "If the patient complains of sore throat, fever, and malaise, the doctor should be contacted to evaluate for a possible dangerous side effect of the mediation." D. "if the male patient begins to show signs of breast enlargement or the female patient experiences amenorrhea, take the patient immediately to the ER." E. "If the patient's psychotic symptoms appear to be absent, call the doctor immediately."

A. "If the patient has acute muscle spasms or the patient's eyes appear to be rolling back, emergency intervention should be sought." B. "if the patient has an unusually high fever and complains of muscle rigidity, any further antipsychotic medication should be discontinued and immediate emergency intervention should be sought." C. "If the patient complains of sore throat, fever, and malaise, the doctor should be contacted to evaluate for a possible dangerous side effect of the mediation." Feedback 1: These symptoms are indicative of an acute dystonia, which can progress to laryngospasm if not treated. Emergency intervention with an anticholinergic such as Cogentin is needed to reverse this side effect. Feedback 2: These symptoms are indicative of neuroleptic malignant syndrome, which can progress rapidly and be fatal. Immediate discontinuation of antipsychotic medication and emergency intervention are critical needs. Feedback 3: These symptoms may be indicative of agranulocytosis, which can be fatal is not treated. Further bloodwork is needed.

A client diagnosed with schizophrenia states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? A. "i know you believe that to be true, but i find that hard to believe." B. "What would make you think such a thing?" C. "I know your roommate. He would do no such thing." D. "I can see why you feel that way."

A. "i know you believe that to be true, but i find that hard to believe." This client is experiencing a persecutory delusion. this nursing response is an example o voicing doubt, which expresses uncertainty as to the reality of the client's perceptions. this is an appropriate therapeutic communication technique in dealing with clients experiencing delusional thinking.

Which of the following instructions regarding lithium therapy should be included in the nurse's discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2500 to 3000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1500 mL per day.

A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2500 to 3000 mL of fluid per day.

A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? A. Identify with the person speaking B. Imitate the nurse's movements C. Alleviate alogia D. Alleviate avolition

A. Identify with the person speaking Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.

A client and nurse therapist are developing a treatment plan that includes strategies to manage bipolar disorder. Which should be included? Select all that apply. A. Maintain a consistent sleep schedule. B. Become an expert on mental health. C. Create a daily medication schedule. D. Set a time frame to achieve remission. E. Develop an emergency plan.

A. Maintain a consistent sleep schedule. B. Become an expert on mental health. C. Create a daily medication schedule. E. Develop an emergency plan.

The clinic nurse is reviewing the medication list of a client diagnosed with Medication-Induced Bipolar Disorder. The nurse recognizes which may have precipitated the client's mood disturbance? Select all that apply. A. Oral contraceptives B. Antihypertensives C. Dopamine agonist D. Corticosteroids E. Alpha-adrenergics

A. Oral contraceptives B. Antihypertensives D. Corticosteroids

Which of the following explanations should the nurse include when teaching parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age. D. The diagnosis of Bipolar Disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant.

A. Symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. B. Children are naturally active, energetic, and spontaneous.

A client who is experiencing command hallucinations is hospitalized after jumping from a bridge. The client's parents insist that their son feel rather than jumped. Which of the following likely explain the parents' response? (Select all that apply) A. The parents are in denial about the reality of their son's mental illness B. The parents are grieving over the loss of their expectations for their child C. The parents do not understand the extent or seriousness of mental illness D. The parents reject the idea of their son having a mental illness E. The parents are showing support for their son.

A. The parents are in denial about the reality of their son's mental illness B. The parents are grieving over the loss of their expectations for their child C. The parents do not understand the extent or seriousness of mental illness D. The parents reject the idea of their son having a mental illness Feedback 1: by stating the jump was a fall, the parents are expressing denial and minimizing the problem Feedback 2: The child's attempted suicide could generate a loss of hope that their child will meet parental expectations. This can occur any time a child is physically or mentally different. Feedback 3: The parents may have a knowledge deficit and truly may not understand the implications of their child's mental illness Feedback 4: By claiming that their son feel rather than jumped from the bridge, the parents are embracing an accidental cause and rejecting the possibility of mental illness.

The family of a client diagnosed with schizophrenia tells the nurse that they were at a NAMI meeting and heard that the recovery model for intervention with people with schizophrenia is gaining recognition as a desirable approach. They ask the nurse to describe this model. Which of these responses by the nurse are accurate statements about the recovery model? (Select all that apply) A. This model supports that recovery is an obtainable objective for people with schizophrenia B. This approach engages the client in an Alcoholics Anonymous (AA) - like 12-step program for recovery C. the recovery model actively engages the client in determining the goals for the treatment plan. D. The recovery model should not be confused with providing a "cure" for schizophrenia E. The recovery model is controversial because it stigmatizes the person with schizophrenia

A. This model supports that recovery is an obtainable objective for people with schizophrenia C. the recovery model actively engages the client in determining the goals for the treatment plan. D. The recovery model should not be confused with providing a "cure" for schizophrenia Feedback 1: Conventional models for treatment in schizophrenia have been criticized for potentially inhibiting a client's ability to recognize his or her potential because they focus too heavily on the disease as one in which recovery is not obtainable. The recovery model shifts the focus toward recovery as an attainable goal. Feedback 3: Central to the recovery model in intervention with people with schizophrenia is a patient-centered approach in which the clinician and the client work together to develop a treatment plan that is in alignment with goals set forth by the client Feedback 4: It is important in educating clients and families that the recovery model is not to be confused with promising a remission or a cure for this illness. Instead, it focuses on potential to function more autonomously rather than a primary focus on managing an intractable illness.

A patient admitted to the psychiatric unit and diagnosed with schizophrenia reports to the nurse that there are people playing drums in his chest. Which of these would be appropriate interventions by the nurse? (Select all that apply) A. check the patient's vital signs B. tell the patient that these are tactile hallucinations and that he need not be concerned C. Ask the patient to describe more completely what he is feeling D. Give the patient PRN Cogentin as ordered E. Encourage the patient to discuss this with the music therapist.

A. check the patient's vital signs C. Ask the patient to describe more completely what he is feeling Feedback 1: This intervention is a priority to ensure that the patient's symptoms are not secondary to a medical emergency such as heart attack. Feedback 3: This is an appropriate intervention since further assessment is needed to ensure that the patient's physiological needs are being met.

A withdrawn client, newly diagnosed with schizophrenia, is experiencing delusional thinking. Which nursing intervention is most appropriate? A. present objective reality B. use self-disclosure C. use physical touch for reassurance D. provide an in-depth explanation of unit rules and regulations

A. present objective reality When communicating with a client diagnosed with schizophrenia, the nurse should reinforce and focus on reality by talking about real events and real people. Discussions that focus on false ideas reinforce the client's delusions.

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

A client diagnosed with major depressive disorder was raised in an excessively religiously based household. Which nursing intervention would be most appropriate to address this client's underlying problem? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

ANS: A A client raised in an excessively religiously based household maybe at risk for experiencing guilt to the point of accepting liability in situations for which one is not responsible. The client may view himself or herself as evil and deserving of punishment leading to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

A nurse reviews the laboratory data of a 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-IV-TR, 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 which results from a low thyroid function or hypothyroidism. In hypothyroidism, metabolic processes are slowed leading to depressive symptoms.

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considering as a treatment option. Clozapine can have a serious side effect of agranulocytosis in which a potentially fatal drop in white blood cells can occur.

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

ANS: A The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client diagnosed with schizophrenia 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. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions

ANS: A, B, C The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs due to the risk of drug interactions.

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? (Select all that apply.) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

ANS: A, B, D, E The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) A. Sad mood on most days B. Mood rating of 2/10 for the past 6 months C. Labile mood D. Sad mood for the past 3 years after spouse's death E. Pressured speech when communicating

ANS: A, D The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than 2 years. The essential feature of dysthymia is a chronically depressed mood which can have an early or late onset.

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

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.

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B Buspar takes at least 2 to 3 weeks to be effective in controlling symptoms of depression. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "I'm glad you shared this. There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe based on assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

What is the rationale 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 can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

A client is admitted with a diagnosis of depression NOS (not otherwise specified). Which client statement would describe a somatic symptom that can occur with this diagnosis? A. "I am extremely sad, but I don't know why." B. "Sometimes I just don't want to eat because I ache all over." C. "I feel like I can't ever make the right decision." D. "I can't seem to leave the house without someone with me."

ANS: B When a client diagnosed with depression expresses physical complaints, the client is experiencing somatic symptoms. Somatic symptoms occur with depression because of a general slowdown of the entire body reflected in sluggish digestion, constipation, impotence, anorexia, difficulty falling asleep, and a wide variety of other symptoms.

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

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 senile dementia D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out senile dementia. The elderly are often misdiagnosed with senile dementia when depression is their actual diagnosis. Memory loss, confused thinking, or apathy symptomatic of dementia actually may be the result of depression.

A 75-year-old client diagnosed with a long history of depression is currently on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? A. According to psychoanalytic theory, depression is a result of anger turned inward. B. According to object-loss theory, depression is a result of abandonment. C. According to learning theory, depression is a result of repeated failures. D. According to cognitive theory, depression is a result of negative perceptions.

ANS: C The nurse should assess that this client's depressive symptoms may have resulted from repeated failures. This assessment was based on the principles of learning theory. Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

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

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular blood work B. The client's mood and affect score, using the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C When a nurse assesses and attempts to modify negative thought patterns related to depressive symptoms, the nurse is using a cognitive theory framework.

Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.

ANS: C Zoloft is a selective serotonin reuptake inhibitor (SSRI) that has a relatively benign side effect profile as compared with other antidepressants.

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.

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. Depressive symptoms are often described as anger turned inward.

A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

A client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. The diagnosis of SAD is not associated with a traumatic event.

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-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.

A client is diagnosed with dysthymic 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 dysthymic disorder. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological.

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

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

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

A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis?

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

Some patients with schizophrenia express lack of insight or awareness that there is anything wrong or that any disorder is present. This symptom is referred to as _____________.

Anosognosia This symptom is often apparent when a client is asked what prompted admission to the hospital. A response such as "for some reason, the police just came over and told me I had to go to the hospital," is evidence of anosognosia. It is considered a symptom of the illness rather than a defense mechanism. A comparable symptom occurs following brain damage.

A client diagnosed with Bipolar Disorder states, "I hate oatmeal. Let's get everybody together to do exercises. I'm thirsty and I'm burning up. Get out of my way; I have to see that guy." Which is the priority nursing action? A. Assess the client's vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.

Assess the client's vital signs.

A client diagnosed with bipolar disorder states, "I hate oatmeal. Let's get everybody together to do exercises. I'm thirsty and I'm burning up. Get out of my way; I have to see that guy." What should be the priority nursing action?

Assess the client's vital signs.

A client on an inpatient unit is diagnosed with Bipolar Disorder: Manic Episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. Which should be the nurse's initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.

Assist the client to move to a calmer location.

A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurse's initial intervention?

Assist the client to move to a calmer location.

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? Select all that apply.

Avoid excessive use of beverages containing caffeine. Maintain a consistent sodium intake. Consume at least 2,500 to 3,000 mL of fluid per day.

A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which of the following would the nurse expect to implement in conjunction with pharmacologic therapy? A) Behavioral therapy B) Cognitive behavioral therapy C) Interpersonal therapy D) Family therapy

B

A nurse is performing an admission assessment for an adolescent girl with an eating disorder who is being admitted to the psychiatric unit. Which statement would the nurse interpret as most likely supporting the client's diagnosis? A) ​My father was always very thin.​ B) ​I've never really liked myself.​ C) ​I have a lot of confidence in myself.​ D) ​I feel really close to my parents and my brother.​

B

The nurse is initiating a group for adolescent girls diagnosed with anorexia nervosa. Many of the clients in the group are irritable and resent having to attend. One of them comments, ​This is a stupid waste of time!​ Which of the response by the nurse would be most appropriate? A) ​If you feel that way, then you can just leave.​ B) ​You sound irritated; tell me about what is bothering you.​ C) ​You were assigned to this group by your therapist, so you must participate.​ D) ​Sit down and be quiet; your peers would appreciate some peace and quiet.​

B

The family of a patient with schizophrenia requests information about Assertive Community Treatment (ACT). Which of the following responses by the nurse are consistent with this treatment model? (Select all that apply) A. "this model of treatment is based in the hospital and provides group education about how to assert oneself in the community." B. "this is a program of case management that takes a team approach in providing comprehensive community-based psychiatric services." C. This model is designed to meet the needs of people with conditions ranging from mild depression to severe and persistent illnesses such as schizophrenia." D. "One of the primary goals of ACT is to lessen the family's burden of providing care."

B. "this is a program of case management that takes a team approach in providing comprehensive community-based psychiatric services." D. "One of the primary goals of ACT is to lessen the family's burden of providing care." Feedback 1: This response demonstrates a lack of understanding of ACT. ACT is a community-based treatment model that focuses on comprehensive management of needs for patients with severe and persistent mental illnesses like schizophrenia. Feedback 4: NAMI (2012) identifies primary goals for ACT, one of which is to lessen the family's burden for providing care. ACT recognizes that patients with severe, persistent mental illness require many services beyond what one resource or the family can provide exclusively

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. the nurse recognizes these behaviors as a symptom of the client's illness. The most appropriate nursing intervention for this symptom is to: A. Ask the client to describe his physical symptoms B. Ask the client to describe what he is hearing C. Administer a dose of benzotropine D. Call the physician for additional orders

B. Ask the client to describe what he is hearing

The primary goal in working with an actively psychotic, suspicious client would be to: A. Promote interaction with others B. Decrease his anxiety and increase trust C. Improve this relationship with his parents D. Encourage participation in therapy activities

B. Decrease his anxiety and increase trust

A client diagnosed with schizophrenia manifests the symptom of mutism. Which nursing intervention would assist the client in communicating with others? A. Providing assistance with self-care needs B. Using clear, concrete statements C. Conveying acceptance of the client's need for false beliefs D. attempting to decode incomprehensible communication patterns.

B. Using clear, concrete statements The use of clear, concrete statement shows the client what is expected. Because clients diagnosed with schizophrenia experience concrete thinking, explanations must be provided at the client's concrete level of comprehension

A client diagnosed with schizophrenia hears another patient say, "You'll be tied up for another hour." and becomes agitated because he interprets that to mean he will literally be tied up. Which cognitive symptom of schizophrenia is this client manifesting? A. nihilistic delusions B. concrete thinking C. circumstantiality D. perseveration

B. concrete thinking Concrete thinking is manifested by literal interpretation of abstract or figurative ideas. This symptom may be present in schizophrenia and is believed to represent regression to an earlier level of cognitive development

Several types of delusions may occur in an individual with schizophrenia. Which of the following types of delusion places the patient at greatest risk for agitation or aggression? A. delusions of grandeur B. delusions of persecution C. delusions of reference D. nihilistic delusions

B. delusions of persecution In delusions of persecution an individual falsely believes he or she is being threatened or persecuted in some way. This carries a high risk for increasing the individual's agitation and possibly aggression in protective efforts.

In planning care to reinforce reality for a client diagnosed with schizophrenia, the nurse should include which interventions? A. explore the client's expressions of distorted thinking B. discuss perceptions and thinking that are in touch with reality C. Encourage the client to share delusional thinking in group discussions. D. ask the client why distorted thinking and bizarre behavior have occurred.

B. discuss perceptions and thinking that are in touch with reality Discussing reality=based perceptions and thinking will assist the client to maintain orientation and will promote organized thinking.

Tony, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Tony is to: A. give him an injection of Thorazine B. ensure a safe environment for him and others C. Place him in restraints. D. Order him a nutritious diet

B. ensure a safe environment for him and others

A nursing home resident who has been taking antipsychotic medications for several months complains to the nurse of a stiff neck and difficulty swallowing. These symptoms are indicative of which condition? A. dysphonia B. tardive dyskinesia C. akathisia D. echolalia

B. tardive dyskinesia Tardive dyskinesia is a syndrome characterized by abnormal, involuntary movements, including bizarre facial and tongue movements, a stiff neck, and/or difficulty swallowing. This condition may occur as an adverse effect of long-term therapy with antipsychotic medications

Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply.

Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms. Children are naturally active, energetic, and spontaneous.

A nurse is reviewing the plan of care for a client with anorexia nervosa and notes a behavioral plan for increasing weight. The nurse correlates this intervention with which nursing diagnosis? a) Disturbed Body Image B) anxiety C) Imbalanced Nutrition: Less Than Body Requirements D) Ineffective Coping

C

The nurse is planning to explain the purpose of the behavioral therapy technique of self-monitoring to a client with bulimia nervosa. The nurse would emphasize keeping a diary to record which of the following? A) Feelings of hunger B) Efforts at distraction C) Environmental stimuli D) Rigid rules about eating

C

A client is admitted with a diagnosis of schizoaffective disorder. Which symptoms are characteristic of this diagnosis? A. strong ego boundaries and abstract thinking B. acute dystonias and tardive dyskinesia C. Altered mood and thought disturbances D. substance abuse and cachexia

C. Altered mood and thought disturbances The characteristic symptoms of schizoaffective disorder are a combination of alterations in mood (mania or depression) and thought

A client who has been taking chlorpromazine (Thorazine) for several months presents in the ED with extrapyramidal symptoms (EPS) of restlessness, drooling and tremors. What medication will the nurse expect the physician to order? A. Paroxetine (Paxil) B. Carbamazepine (Tegretol) C. Benztropine (Cogentin) D. Lorazepam (Ativan)

C. Benztropine (Cogentin) Benztropine is an anticholinergic medication that blocks cholinergic activity in the CNS, which is responsible for EPS. Anticholinergics are the drugs of choice to treat extrapyramidal symptoms associated with antipsychotic mediations

A client who has been taking chlorpromazine (Thorazine) for several months presents in the ED with extrapyramidal symptoms of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order? A. Paroxetine (Paxil) B. Carbamazepine (Tegretol) C. Benztropine (Cogentin) D. Lorazepam (Ativan)

C. Benztropine (Cogentin) Cogentin is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for extrapyramidal symptoms. This is the drug of choice to treat extrapyramidal symptoms associated with antipsychotic medications.

When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? A. Provide large motor activities to relieve the client's pent-up tension. B. Administer a dose of PRN chlorpromazine to keep the client calm. C. Call for sufficient help to control the situation safely. D. Convey to the client that his behavior is unacceptable and will not be permitted.

C. Call for sufficient help to control the situation safely.

A client is admitted with a diagnosis of brief psychotic disorder with catatonic features. Which symptoms are associated with the catatonic specifier? A. Strong ego boundaries and abstract thinking B. Ataxia and akinesia C. Stupor, muscle rigidity, and negativism D. substance abuse and cachexia

C. Stupor, muscle rigidity, and negativism Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid PRN. Why is chlorpromazine ordered? A. To reduce extrapyramidal symptoms B. To prevent neuroleptic malignant syndrome C. To decrease psychotic symptoms D. To induce sleep

C. To decrease psychotic symptoms

The nurse is interviewing a client on the psychiatric unit. The client tilts is head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing: A. somatic delusions B. catatonic stupor C. auditory hallucinations D. pseudoparkinsonism

C. auditory hallucinations

A client is experiencing paranoia and states, "the FBI and phone company are plotting against me." Which charting entry best describes this client's symptom? A. experiencing delusions of grandeur B. experiencing erotomanic delusions C. experiencing delusions of persecution D. experiencing somatic delusions

C. experiencing delusions of persecution Individuals experiencing delusions of persecution feel that they are being threatened and believe that others have harmful intentions. The client in the question believes that the FBI and the phone company are plotting harm.

The client hears the word "match". the client replies, "A match. I like matches. They are the light of the world. God will light the world. Let your light so shine." Which communication pattern does the nurse identify? A. word salad B. clang association C. Loose association D. ideas of reference

C. loose association Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question represents this communication pattern.

The client hears the word "match". The client says, "A match. Tomorrow is the end of the world. Nothing is better than hot coffee." Which communication pattern does the nurse identify? A. word salad B. clang association C. loose association D. ideas of reference

C. loose association Loose association is characterized by communication in which ideas shit from one unrelated topic to another. The situation in the question clearly represents this communication pattern

The nurse is providing care for an emaciated client experiencing an acute phase of catatonic stupor. Which nursing intervention would take priority when meeting this client's needs? A. minimize attempts to communicate with the client B. assist the client to ambulate C. provide nutrient-dense foods and beverages D. place the patient is seclusion for safety

C. provide nutrient-dense foods and beverages Nutrition is an essential consideration for a client with catatonic stupor. The emaciated client in the question is suffering from malnutrition. The nurse must prioritize this basic physical need.

A client has been admitted to the inpatient psychiatric unit and is manifesting mutism. His diagnosis is schizophrenia with catotonia. What would the nurse expect to observe? A. frenzied and purposeless movements B. exaggerated suspiciousness C. stuporous withdrawal D. sexual preoccupation

C. stuporous withdrawal The client's mutism indicates catatonic stupor. This client would be noted to have extreme psychomotor retardation, and efforts to move the individual may be met with bodily resistence

A client diagnosed with schizophrenia is experiencing disorganized thinking. Which technique should the nurse use to promote communication? A. giving broad openings B. probing C. verbalizing the implied D. using open-ended questions

C. verbalizing the implied When working with clients who have greatly impaired communication ability, the nurse can use the technique of verbalizing the implied. By putting into words what the client may be experiencing, the nurse helps the client to organize his or her thinking.

A client with bulimia nervosa is being treated at an outpatient clinic and is prescribed a selective serotonin reuptake inhibitor (SSRI). Which of the following would the nurse include when teaching the client about the prescribed medication? A) Closely monitor your fluid intake while taking this medication. B) Stop taking this medication if it causes weight gain. C) Expect menstrual irregularities, particularly if they've occurred previously. D) Report any weight changes that occur during the first few weeks this medication is taken.

D

A nurse is interviewing a client diagnosed with bulimia nervosa about her family and her relationship with her mother. Which statement by the client would the nurse least likely associate with bulimia nervosa? A) ​My mother is my confidante for everything.​ B) My mother's happiness depends on me.​ C) My family basically has very few rules.​ D) ​My mother and I are close but not joined at the hip.​

D

The nurse is preparing to discharge a client who has been hospitalized with anorexia nervosa. Which of the following would the nurse include in the teaching plan? A) Knowing the calorie content of numerous foods B) Learning strategies to control impulses C) Describing physiologic consequences of anorexia nervosa D) Setting realistic goals

D

Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: A. "That's ridiculous, Clint. No one is going to hurt you." B. "The CIA isn't interested in people like you, Clint." C. "Why do you think the CIA wants to kill you?" D. "I know you believe that, Clint, but it's really hard for me to believe."

D. "I know you believe that, Clint, but it's really hard for me to believe."

Which medication does the nurse determine will give the client the most immediate relief from neuroleptic-induced extrapyramidal side effects? A. lorazepam (Ativan), 1 mg PO B. Diazepam (Valium), 5 mg PO C. Haloperidol (Haldol), 2 mg IM D. Benztropine (Cogentin), 2 mg PO

D. Benztropine (Cogentin), 2 mg PO The symptoms of neuroleptic-induced extrapyramidal side effects include tremors, chorea, dystonia, akinesia, and akahesia. Congentin, 1-4 mg given once or twice daily, is the drug of choice to treat these symptoms.

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT, and then 50 mg PO bid; 2 mg benztropine PO bid PRN. Because benztropine was ordered on a PRN basis, which of the following assessments by the nurse would convey a need for this medication? A. The client's level of agitation increases B. The client complains of a sore throat C. The client's skin has a yellowish cast. D. The client develops tremors and a shuffling gait.

D. The client develops tremors and a shuffling gait.

The primary focus of family therapy for clients with schizophrenia and their families is: A. to discuss concrete problem solving and adaptive behaviors for coping with stress B. To introduce the family to others with the same problem C. To keep the client and family in touch with the health care system D. To promote family interaction and increase understanding of the illness

D. To promote family interaction and increase understanding of the illness

To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? A. Reinforce the perceptual distortions until the client develops new defenses B. Provide an unstructured environment C. Avoid making connections between anxiety-producing situations and hallucinations D. distract the client's attention

D. distract the client's attention The nurse should first empathize with the client by focusing on feelings generated by the hallucination, present objective reality, and then distract or redirect the client to reality-based activities.

To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented? A. reinforce the perceptual distortions until the client develops new defenses. B. Provide an unstructured environment C. avoid making connections between anxiety-producing situations and hallucinations D. use empathic listening and redirect the client's attention to reality-based interaction

D. use empathic listening and redirect the client's attention to reality-based interaction The nurse should first empathize with the client by focusing on feelings generarted by the hallucination, present objective reality, and then redirect the client to reality-based activites

Which tool should the nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool

FIND tool

A newly admitted client is diagnosed with Bipolar Disorder: Manic Episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability

Flight of ideas

A client who has been diagnosed with bipolar I disorder states, "God has taught me how to decode the Bible." A nurse should anticipate that which combination of medications would be ordered to address this client's symptoms?

Lithium carbonate (Lithobid) and risperidone (Risperdal)

A client diagnosed with Bipolar Disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. The nurse should interpret these symptoms to be indicative of which of the following? A. Consumption of foods high in tyramine B. Lithium carbonate discontinuation syndrome C. Development of lithium carbonate tolerance D. Lithium carbonate toxicity

Lithium carbonate toxicity

A patient on antipsychotic medication reports to the nurse that her muscles feel very stiff, and she appears diaphoretic. Her temperature is 105 degrees. Her symptoms are indicative of the potentially fatal adverse reaction to antipsychotic medication known as ________________________

Neuroleptic Malignant Syndrome Although neuroleptic malignant syndrome is rare, its rapid progression and potential to cause death make it a priority to assess for regularly and to intervene aggressively when symptoms are apparent. Antipsychotic medication should be immediately discontinued

A client is diagnosed with Bipolar I Disorder: Manic Episode. Which nursing intervention should be implemented to achieve the outcome of "Client will gain 2 pounds by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

Provide client with high-calorie finger foods throughout the day.

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 pounds by the end of the week?"

Provide client with high-calorie finger foods throughout the day.

The nurse is planning care for a client diagnosed with Bipolar Disorder: Manic Episode. Which should be the first priority of the listed client outcomes? A. Maintains nutritional status B. Interacts appropriately with peers C. Remains free from injury D. Sleeps 6 to 8 hours a night

Remains free from injury

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes?

Remains free from injury. Maintains nutritional status. Sleeps 6 to 8 hours a night. Interacts appropriately with peers.

A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client?

Risk for violence: directed toward others R/T agitation and hyperactivity

A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

Risk for violence: directed toward others R/T agitation and hyperactivity

The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom décor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate?

Rooms should be painted with neutral colors and contain pale-colored accessories.

The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom décor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? A. Rooms should contain extra-large windows with views of the street. B. Rooms should contain brightly colored walls with printed drapes. C. Rooms should be painted deep colors and located close to the nurse's station. D. Rooms should be painted with neutral colors and contain pale-colored accessories.

Rooms should be painted with neutral colors and contain pale-colored accessories.

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

Symptoms indicate lithium carbonate toxicity.

A client is diagnosed with Cyclothymic Disorder. Which client behaviors should the nurse expect to assess? A. The client expresses "feeling blue most of the time." B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.

The client has endured periods of elation and dysphoria lasting for more than 2 years.

A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess?

The client has endured periods of elation and dysphoria lasting for more than 2 years.

A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, "You can't do this to me. Do you know who I am?" Which is the priority nursing action in this situation?

To provide self and client with a safe environment

The nurse begins the intake assessment of a client diagnosed with Bipolar I Disorder. The client shouts, "You can't do this to me. Do you know who I am?" Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation

To provide self and client with a safe environment

A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention is most therapeutic for this client? A. Use a calm, unemotional approach during client interactions. B. Focus primarily on enforcing limits. C. Limit interactions to decrease external stimuli. D. Encourage the client to establish social relationships with peers.

Use a calm, unemotional approach during client interactions.

A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client?

Using a calm, unemotional approach during client interactions

A client diagnosed with Bipolar I Disorder: Manic Episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

Valproic acid (Depakote)

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders?

Valproic acid (Depakote)

A group of nursing students is reviewing the similarities and differences between bulimia nervosa and binge-eating disorder. The students demonstrate understanding when they identify which characteristics as specific to binge-eating disorder? Select all that apply. A) Clients typically are obese. B) Clients refrain from purging behaviors. C) Binge-eating periods are shorter. D) Clients engage in overexercising. E) Feelings of guilt do not occur after binging.

a, b

A nurse is preparing a presentation for a local middle school health class about eating disorders as a means for prevention and early detection. Which of the following would the nurse incorporate into the presentation as being common to both anorexia nervosa and bulimia nervosa? Select all that apply. A) Body dissatisfaction B) Feelings of control C) Obsessiveness D) Boundary problems E) Sexuality fears F) Cognitive distortions

a, c, f

A nursing instructor is reviewing the various theories related to anorexia nervosa. Which of the following would the instructor include when describing theories related to the biologic domain? Select all that apply. A) Genetic vulnerability B) Separation​individuation C) Role pressures D) Dieting leading to starvation E) Pursuit of thinness F) Decreased serotonin activity

a, d, f

The nurse is caring for several hospitalized clients with anorexia nervosa. The nurse would be especially alert for which of the following if noted in the clients' histories? A) paranoia B) primary insomnia C) depression D) aggression

c

An adolescent is brought to the emergency department by her parents because they were concerned about their daughter's appearance. The client appears emaciated and pale. The parents tell the nurse that the client has been diagnosed with anorexia nervosa. A history and physical examination and laboratory testing are completed. Which of the following would lead the nurse to suspect that the client will be admitted to the hospital? Select all that apply. A) Blood pressure of 110/60 mm Hg B) Elevated serum potassium level C) Decreased serum magnesium level D) Heart rate of 40 beats/min E) Statements of being ​hopeless​

c, d, e

While talking with a client with an eating disorder, the client states, ​I've gained 2 pounds, so soon I'll be over 100 pounds.​ The nurse interprets this as which of the following? A) magnification B) selective abstraction C) overgeneralization D) dichotomous thinking

d