Essentials of Psychiatric Mental Health Nursing Chapters 1-24

35. Which would the nurse consider a priority intervention when planning care for a medically unstable client diagnosed with alcohol use disorder? 1) Simplifying the environment 2) Addressing physical needs 3) Providing opportunities for success experiences 4) Establishing a trusting interpersonal relationship

2) Addressing physical needs Physical problems must be addressed prior to meeting any psychosocial needs of a client who is medically unstable. According to Maslow's hierarchy of needs, physiological needs should be prioritized over all other needs.

38. When teaching a client diagnosed with alcoholism about nutritional needs, which nutritional concept should the nurse emphasize? 1) Eat a high-protein, low-carbohydrate diet to promote lean body mass. 2) Increase sodium-rich foods to increase iodine levels. 3) Provide multivitamin supplements, including thiamine and folic acid. 4) Restrict fluid intake to decrease renal load.

3) Provide multivitamin supplements, including thiamine and folic acid. Vitamin B deficiencies contribute to the nervous system disorders seen in chronic alcohol abuse. Supplements of these vitamins are important to prevent complications. It is important that vitamin supplements include both thiamine (vitamin B1) and folic acid.

27. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.

A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behaviour by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgemental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: A In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviours are part of the parent's role. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention.

9. The staff development coordinator plans to teach the use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

ANS: A Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

1. An individual says to the nurse, "I feel so stressed out lately. I think the stress is affecting my body also." Which somatic complaints are most likely to accompany this feeling? Select all that apply. a. Headache b. Neck pain c. Insomnia d. Anorexia e. Myopia

ANS: A, B, C, D When individuals feel "stressed-out," they often have accompanying somatic complaints, especially associated with sleep, eating, and headache or back pain. Changes in vision, such as myopia, would not be expected.

6. As part of the stress response, the HPA axis is stimulated. Which structures make up this system? a. Hippocampus, parietal lobe, and amygdala b. Hypothalamus, pituitary gland, and adrenal glands c. Hind brain, pyramidal nervous system, and anterior cerebrum d. Hepatic artery, parasympathetic nervous system, and acoustic nerve

ANS: B As part of the physiologic response of stress, the hypothalamus stimulates the HPA axis, which is made up of the hypothalamus, pituitary gland, and adrenal glands.

5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety.

7. Cortisol is released in response to a patient's prolonged stress. Which initial effect would the nurse expect to result from the increased cortisol level? a. Diuresis and electrolyte imbalance b. Focused and alert mental status c. Drowsiness and lethargy d. Restlessness and anxiety

ANS: B Cortisol is the primary stress hormone and is released in response to prolonged stress. Cortisol helps supply cells with amino acids and fatty acids for energy supply, as well as diverting glucose from muscles for use by the brain. As a result, the brain stays alert and focused. The distractors present effects that would not be expected.

A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse's next best action? a. Report the findings to the health care provider. b. Assess the patient for a history of renal problems. c. Assess the patient's family history for cardiac problems. d. Arrange for the patient's hospitalization on the psychiatric unit.

ANS: B Elevated BUN (blood urea nitrogen) and creatinine suggest renal problems. Renal dysfunction can often imitate psychiatric disorders. The nurse should further assess the patient's history for renal problems and then share the findings with the health care provider.

10. A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

ANS: B Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli; although the experience is similar, the more accurate term is flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience is stimulated by an actual environmental sound.

A black patient says to a white nurse, "There's no sense talking. You wouldn't understand because you live in a white world." The nurse's best action would be to: a. explain, "Yes, I do understand. Everyone goes through the same experiences." b. say, "Please give an example of something you think I wouldn't understand." c. reassure the patient that nurses interact with people from all cultures. d. change the subject to one that is less emotionally disturbing.

ANS: B Having the patient speak in specifics rather than globally will help the nurse understand the patient's perspective. This approach will help the nurse engage the patient. Reassurance and changing the subject are not therapeutic techniques.

37. A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

ANS: B Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters.

13. A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl)

ANS: B Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.

10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

23. A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

8. Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion. REF: Page 473

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

A nurse wants to enhance growth of a patient by showing positive regard. The nurse's action most likely to achieve this goal is: a. making rounds daily. b. staying with a tearful patient. c. administering medication as prescribed. d. examining personal feelings about a patient.

ANS: B Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse's ability to be therapeutic.

A nurse wants to find a description of diagnostic criteria for anxiety disorders. Which resource would have the most complete information? a. Nursing Outcomes Classification (NOC) b. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) c. The ANA's Psychiatric-Mental Health Nursing Scope and Standards of Practice d. International Statistical Classification of Diseases and Related Health Problems (ICD-10)

ANS: B The DSM-5 details the diagnostic criteria for psychiatric clinical conditions. The other references are good resources but do not define the diagnostic criteria.

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.

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.

3. Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with somatic symptom disorder? A. The client will admit to fabricating physical symptoms to gain benefits by day 3. B. The client will list three potential adaptive coping strategies to deal with stress by day 2. C. The client will comply with medical treatments for physical symptoms by day 3. D. The client will openly discuss physical symptoms with staff by day 4.

ANS: B The nurse should determine that an appropriate outcome for a client diagnosed with somatic symptom disorder would be for the client to list three potential adaptive coping strategies to deal with stress by day 2. Because the symptoms of somatic symptom disorder are associated with psychosocial distress, increasing coping skills may help the client reduce 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 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 24 hours. Which client symptom should the nurse immediate report to the ED physician? A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

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.

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

ANS: C Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident. REF: Page 461-463 (Table 24 - 2)

25. A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

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.

Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a patient diagnosed with bulimia nervosa who weighs 60 kg and who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

Questions the nurse could ask that would be nonjudgmental when obtaining information about patient use of herbal remedies include: (select all that apply) a. "You don't regularly take herbal remedies, do you?" b. "What herbal medicines have you used to relieve your symptoms?" c. "What over-the-counter medicines and nutritional supplements do you use?" d. "What differences in your symptoms do you notice when you take herbal supplements?" e. "Have you experienced problems from using herbal and prescription drugs at the same time?"

B, C, D, E The correct responses are neutral in tone and do not express bias for or against the use of herbal medicines. The distracter, worded in a negative way, makes the nurse's bias evident.

Which actions violate the civil rights of a psychiatric patient? The nurse: (select all that apply) (2) a. performs mouth checks after overhearing a patient say, "I've been spitting out my medication." b. begins suicide precautions before a patient is assessed by the health care provider. c. opens and reads a letter a patient left at the nurse's station to be mailed. d. places a patient's expensive watch in the hospital business office safe. e. restrains a patient who uses profanity when speaking to the nurse.

CE

Which individual with mental illness may need emergency or involuntary admission? The individual who: a. resumes using heroin while still taking naltrexone (ReVia). b. reports hearing angels playing harps during thunderstorms. c. does not keep an outpatient appointment with the mental health nurse. d. throws a heavy plate at a waiter at the direction of command hallucinations.

D

dual diagnosis

mental disorder and substance abuse

A nurse consistently strives to demonstrate caring behaviors during interactions with patients. Which reaction by a patient indicates this nurse is effective? A patient reports feeling: a. distrustful of others. b. connected with others. c. uneasy about the future. d. discouraged with efforts to improve.

ANS: B A patient is likely to respond to caring with a sense of connectedness with others. The absence of caring can make patients feel distrustful, disconnected, uneasy, and discouraged.

31. The ED nurse assesses a confused client diagnosed with alcohol use disorder and notes the use of confabulation. Which complication of alcohol use disorder would the nurse suspect? 1) Korsakoff's psychosis 2) Vascular neurocognitive disorder 3) Wernicke's encephalopathy 4) Esophageal varices

Korsakoff's psychosis is identified by a syndrome of confusion, loss of memory, and confabulation. Confabulation is the creating of imaginary events to fill in memory gaps.

Patients with borderline personality disorder (BPD) exhibit negative effect, which includes emotional _____________, described as rapidly moving from one emotional extreme to another.

Lability

psychoanalytic theory

Theorist: Freud Tenet: unconscious thoughts; psychosexual development therapeutic model: psychoanalysis to learn unconscious thoughts; therapist is nondirective and interprets meaning

16. A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

a. name two community resources that can be contacted.

safety needs

include security, protection, freedom from fear/anxiety/chaos, and the need for law, order., and limits

love and belonging needs

people have a need for an intimate relationship, love affection, and belonging and will seek to overcome feelings of loneliness and alienation..

esteem needs

people need to have a high self-regard and have it eflected to them from others.

What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Unmet patient needs currently present c. Goals and outcomes for the plan of care d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

ANS: B, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

Which patient meets criteria for involuntary hospitalization for psychiatric treatment? The patient who: a. is noncompliant with the treatment regimen. b. fraudulently files for bankruptcy. c. sold and distributed illegal drugs. d. threatens to harm self and others.

D

59. Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

b. "I have no one for help or support."

29. The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape crisis center.

d. Patient agrees to keep a follow-up appointment with the rape crisis center.

25. A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Anger b. Concern c. Empathy d. Compassion

a. Anger

53. Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

a. As depression lifts, physical energy becomes available to carry out suicide.

20. An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care.

3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b. Sympathy for the victim and anger toward the abuser

Two hospitalized patients fight whenever they are together. During a team meeting, a nurse asserts that safety is of paramount importance, so treatment plans should call for both patients to be secluded to keep them from injuring each other. This assertion: a. reinforces the autonomy of the two patients. b. violates the civil rights of both patients. c. represents the intentional tort of battery. d. correctly places emphasis on safety.

B

An individual is experiencing problems with memory. Which of these structures are most likely to be involved in this deficit? Select all that apply. a. Amygdala b. Hippocampus c. Occipital lobe d. Temporal lobe e. Basal ganglia

A, B, D The frontal, parietal, and temporal lobes of the cerebrum play a key role in the storage and processing of memories. The amygdala and hippocampus also play roles in memory. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement, as well as some thoughts and emotions.

49. A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."

c. "For the next 24 hours, I will not kill or harm myself in any way."

20. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

Complete this analogy. NANDA: clinical judgment: NIC: _________________ a. patient outcomes b. nursing actions c. diagnosis d. symptoms

ANS: B Analogies show parallel relationships. NANDA, the North American Nursing Diagnosis Association, identifies diagnostic statements regarding human responses to actual or potential health problems. These statements represent clinical judgments. NIC (Nursing Interventions Classification) identifies actions provided by nurses that enhance patient outcomes. Nursing care activities may be direct or indirect.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 32 kg; height is 172 cm. The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation

ANS: D The physical assessment shows hypercarotenemia and lanugo which indicate imbalanced nutrition. Addressing the patient's self-starvation is the priority.

Which instruction has priority when teaching a patient about clozapine (Clozaril)? a. "Avoid unprotected sex." b. "Report sore throat and fever immediately." c. "Reduce foods high in polyunsaturated fats." d. "Use over-the-counter preparations for rashes."

B Clozapine therapy may produce agranulocytosis; therefore, signs of infection should be immediately reported to the health care provider. In addition, the patient should have white blood cell levels measured weekly. The other options are not relevant to clozapine.

The Theory of interpersonal relationships developed by Hildegard Peplau is based on the foundation provided by which of the following early theorists? A. Freud B. Piaget C. Sullivan D. Maslow

C. Sullivan

id

the id is primitive, pleasure-seeking part of our personalities that lurks in the unconscious mind

33. A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

b. explain that washing would destroy evidence.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

15. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you began feeling depressed."

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.

5. A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? A. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness." B. "When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. C. "People with dissociative disorders typically have strong egos." D. "There is clear and convincing evidence of a familial predisposition to this disorder."

ANS: A The nurse should understand that from a psychoanalytical perspective, dissociation occurs because of repression of painful information or experiences.

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates: a. boundary blurring. c. positive regard. b. sexual harassment. d. advocacy.

ANS: A When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming over-involved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

*After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?* a. The patient's reactions toward the nurse seem realistic and appropriate. b. The patient states, "Talking to you feels like talking to my parents." c. The nurse feels unusually happy when the patient's mood begins to lift. d. The nurse develops a trusting relationship with the patient.

ANS: C Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable.

9. A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, "I am not going to harm myself, I am going to kill myself," or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

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 psychiatric clinical nurse specialist uses cognitive-behavioural therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

ANS: D The correct response is the only strategy that attempts to question the patient's distorted thinking. As patients begin to eat again, they ideally participate in milieu therapy, in which the cognitive distortions (errors in thinking) that perpetuate the illness are consistently addressed by all members of the interdisciplinary team.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. Which drug action causes these symptoms to develop? a. Anticholinergic effects b. Dopamine-blocking effects c. Endocrine-stimulating effects d. Ability to stimulate spinal nerves

B Medication that blocks dopamine often produces disturbances of movement, such as akathisia, because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

The premise that an individual's behavior and affect are largely determined by the attitudes and assumptions the person has developed about the world underlies: A. modeling B. Milleu therapy C. Cognitive behavioral theory D. Psychoanalytic psychotherapy

C. Cognitive behavioral theory

A patient's history shows drinking 4 to 6 liters of fluid and eating more than 6,000 calories per day. Which part of the central nervous system is most likely dysfunctional for this patient? a. Amydala b. Parietal lobe c. Hippocampus d. Hypothalamus

D The hypothalamus, a small area in the ventral superior portion of the brainstem, plays a vital role in such basic drives as hunger, thirst, and sex.

biological theory

Theorist: Many Tenet: psychiatric disorders are the result of physical (brain) alterations Therapeutic model: neurochemical imbalances are corrected through medication and talk therapy

Interpersonal theory

Theorist: Sullivan Tenet: relationships as basis for mental health or illness Therapeutic model: therapy focuses on here and now and emphasizes relationships; therapist is an active participant

61. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night

30. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

a. Use accepting, nurturing, and empathetic communication techniques.

46. A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

a. denial.

15. After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

b. Risk for injury, related to partner's physical abuse when intoxicated

11. A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

c. "How did this happen to you?"

28. A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

c. "You believe this would not have happened if you had not been alone?"

45. A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

32. A nurse working a rape telephone hotline should focus communication with callers to: a. arrange long-term counseling. b. serve as a sympathetic listener. c. obtain information to relay to the local police. d. explain immediate steps that a victim of rape should take.

d. explain immediate steps that a victim of rape should take.

physiological needs

the most basic needs are the physical drives, including the need for food, oxygen, water, sleep, sex, and a constant body temperature

behavioral theory

theorist: Pavlov, Watson-Skinner Tenet: behavior is learned through conditioning Therapeutic model: behavioral modification addresses maladaptive behaviiors by rewarding adaptive behavior

31. What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

d. Desire to humiliate or control others

26. A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. "She was very beautiful." b. "I gave her what she wanted." c. "I have issues with my mother." d. "I've been depressed for a long time."

b. "I gave her what she wanted."

51. A client with chronic alcoholism says to the nurse, "I'm tired of using and I want to stop. Is there a medication that can help me maintain sobriety?" About which medication would the nurse provide information? 1) Carbamazepine (Tegretol) 2) Clonidine (Catapres) 3) Disulfiram (Antabuse) 4) Folic acid (Folvite)

3) Disulfiram (Antabuse) Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. It can even result in death if blood alcohol levels are high enough. It is important that the client understands that all alcohol, oral or topical, and medications that contain alcohol are strictly prohibited when taking this drug.

A patient's sibling says, "My brother has a mental illness, but the doctor ordered a functional magnetic resonance image (fMRI) test. That test is too expensive and will just increase the hospital bill." Select the nurse's best responses. Select all that apply. a. "Sometimes there are physical causes for psychiatric symptoms. This test will help us understand whether that is the situation." b. "Some mental illnesses are evident on fMRIs. This test will give information to help us plan the best care for your brother." c. "Tell me more about what kinds of tests your brother's health insurance plan covers." d. "It sounds like you do not truly believe your brother had a mental illness." e. "It would be better for you to discuss your concerns with the doctor."

A, B The correct responses provide information to the sibling. Modern imaging techniques are important tools in assessing molecular changes in mental disease and marking the receptor sites of drug action, which can help in treatment planning. Psychiatric symptoms can be caused by anatomical or physiologic abnormalities. There is no evidence of denial in the sibling's comment. The nurse can answer this question rather than referring it to the physician. It would be inappropriate to discuss finances with the patient's sibling.

Providing a safe environment for patients with impaired cognition, referring an abused spouse to a "safe house", and conducting a community meeting are nursing interventions that address aspects of: A. Milleu therapy B. Cognitive therapy C. Behavioral therapy d. Interpersonal psychotherapy

A. Milleu therapy

33. A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

ANS: A Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.

21. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

ANS: A The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation? a. "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." b. "The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented." c. "The focus of the relationship is socialization. Mutual needs are met, and feelings are shared openly." d. "The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other."

ANS: A Only the correct response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

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.

25. A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

Which descriptors exemplify consistency regarding nurse-patient relationships? Select all that apply. a. Encouraging a patient to share initial impressions of staff b. Having the same nurse care for a patient on a daily basis c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patient e. Offering solutions to a patient's problems

ANS: B, C, D Consistency implies predictability. Having the same nurse see the patient daily and provide a daily schedule of patient activities and a set time for regular sessions will help a patient predict what will happen during each day and develop a greater degree of security and comfort. Encouraging a patient to share initial impressions of staff and giving advice are not related to consistency and would not be considered a therapeutic intervention.

15. A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: C Physiologic reactions to reminders of the event include a persistent avoidance of the stimuli associated with the trauma; the individual avoids talking about the event or avoids activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. No evidence suggests that this soldier is having a hyperarousal reaction or is re-experiencing war-related traumas. Psychosis is not evident.

*Termination of a therapeutic nurse-patient relationship has been successful when the nurse:* a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that happened during the relationship and evaluates outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.

ANS: C Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact.

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 32 kg and is 162 cm. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. "I can always trust my family." b. "It seems like I always have bad luck." c. "You never know who will turn against you." d. "I hear evil voices that tell me to do bad things."

ANS: D The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations and may create risks for violence. The other statements are vague and do not clearly identify the patient's chief symptom.

48. An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

a. Supervise the patient 24 hours a day.

37. A survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

b. plans coping strategies for fearful situations.

35. When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

b. provide referral information verbally and in writing.

54. A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

c. "I have a plan that will fix everything."

Clients with eating disorders often exhibit similar symptoms. The nurse would expect an adolescent client with anorexia to exhibit: A. Disheveled and unkempt physical appearance B. Depersonalization and derealization C. Repetitive motor mechanism D. Affective instability

ANS: D

7. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

b. Report the suspected abuse or neglect according to state regulations.

42. A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room

c. Giving away sweaters

43. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

c. suicide potential.

51. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."

d. "Bringing this up is a very positive action on your part."

36. A client who is going through alcohol detoxification states, "I see bugs crawling on the wall." Which is the best nursing response? 1) "I'll remove the bugs from the wall." 2) "You are confused because of your alcoholism." 3) "There are no bugs on the wall. I'll stay with you until you feel less anxious." 4) "You do not see any bugs on the wall."

3) "There are no bugs on the wall. I'll stay with you until you feel less anxious." This response presents objective reality and may help decrease the client's anxiety by the nurse's therapeutic offering of self.

A newly admitted patient diagnosed with major depression has gained 20 pounds over a few months and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: more than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

ANS: C Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, hopelessness, and chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as would a suicide attempt.

Which disorder is a culture-bound syndrome? a. Epilepsy b. Schizophrenia c. Running amok d. Major depression

ANS: C Culture-bound syndromes occur in specific sociocultural contexts and are easily recognized by people in those cultures. A syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in furious, almost indiscriminate violent behavior.

7. A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? A. It is a means to attain secondary gain. B. It is a means to explore feelings of excessive and inappropriate guilt. C. It serves to isolate painful events so that the primary self is protected. D. It serves to establish personality boundaries and limit inappropriate impulses.

ANS: C The nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress.

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.

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. The nurse should: a. suppress the angry feelings. b. express the anger openly and directly with the patient. c. tell the nurse manager to assign the patient to another nurse. d. discuss the anger with a clinician during a supervisory session.

ANS: D The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings.

11. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."

ANS: D This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem-solving strategies.

A nurse cares for a group of patients receiving various medications, including haloperidol (Haldol), carbamazepine (Tegretol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient who takes: a. carbamazepine b. haloperidol c. phenelzine d. trazodone

C Patients taking phenelzine, an MAO inhibitor, must be on a low tyramine diet to prevent hypertensive crisis. There are no specific dietary precautions associated with the distracters.

A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group? a. tricyclic antidepressants b. antipsychotic drugs c. antimanic drugs d. benzodiazepines

D Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Antimanic drugs are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. "You must have been very upset when you tried to hurt yourself." b. "It makes me sad to see you going through such a difficult experience." c. "If you tell me what is troubling you, I can help you solve your problems." d. "Suicide is a drastic solution to a problem that may not be such a serious matter."

ANS: A Empathy permits the nurse to see an event from the patient's perspective, understand the patient's feelings, and communicate this to the patient. The incorrect responses are nurse- centered (focusing on the nurse's feelings rather than the patient's), belittling, and sympathetic.

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.

In which situations would a nurse have the duty to intervene and report? Select all that apply. (2) a. A peer has difficulty writing measurable outcomes. b. A health care provider gives a telephone order for medication. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member violates relationship boundaries with a patient. e. A patient refuses medication prescribed by a licensed health care provider.

CD

40. A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

a. "Are you thinking of suicide?"

39. Which nursing intervention relates to rehabilitative care for a recovering alcoholic? 1) Providing a safe and supportive environment during alcohol withdrawal 2) Teaching about physical symptoms 3) Providing client and family education and assistance during treatment 4) Encouraging continued participation in AA

4) Encouraging continued participation in AA Because recovery is a long-term process, it is critical that the nurse encourage continuous participation in outpatient support systems such as AA.

42. Which is the most serious symptom experienced during alcohol withdrawal? 1) Blackout 2) Acute withdrawal delirium 3) Hypotension 4) Seizure

4) Seizure During alcohol withdrawal, the central nervous system (CNS) rebounds from the effects of suppression caused by alcohol intake. This excitation of the CNS can lead to grand mal seizures and other complications, which are life threatening. This is the most serious complication of alcohol withdrawal syndrome.

A psychiatric nurse best applies the ethical principle of autonomy by: a. exploring alternative solutions with a patient, who then makes a choice. b. suggesting that two patients who were fighting be restricted to the unit. c. intervening when a self-mutilating patient attempts to harm self. d. staying with a patient demonstrating a high level of anxiety.

A

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. "What are the common elements here?" b. "Tell me again about your experiences." c. "Am I correct in understanding that . . ." d. "Tell me everything from the beginning."

ANS: C Asking, "Am I correct in understanding that..." permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.

Documentation in a patient's chart shows, "Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.'" Which analysis is most accurate? a. The patient is giving positive feedback about the nurse's communication techniques. b. The nurse is viewing the patient's behavior through a cultural filter. c. The patient's verbal and nonverbal messages are incongruent. d. The patient is demonstrating psychotic behaviors.

ANS: C When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. Some clinicians call it a "mixed message." It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.

10. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

ANS: C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: 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, coarse tremors, and seizure activity.

A patient has disorganized thinking associated with schizophrenia. Neuroimaging would likely show dysfunction in which part of the brain? a. Hippocampus b. Frontal lobe c. Cerebellum d. Brainstem

B The frontal lobe is responsible for intellectual functioning. The hippocampus is involved in emotions and learning. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

Consider these medications: carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin). Which medication below also belongs with this group? a. Galantamine (Reminyl) b. Valproate (Depakote) c. Buspirone (BuSpar) d. Tacrine (Cognex)

B The medications listed in the stem are mood stabilizers, anticonvulsant types. Valproate (Depakote) is also a member of this group. The distracters are drugs for treatment of Alzheimer's disease and anxiety.

The parent of an adolescent diagnosed with schizophrenia asks the nurse, "My child's doctor ordered a PET. What kind of test is that?" Select the nurse's best reply. a. "This test uses a magnetic field and gamma waves to identify problem areas in the brain. Does your teenager have any metal implants?" b. "PET means positron-emission tomography. It is a special type of scan that shows blood flow and activity in the brain." c. "A PET scan passes an electrical current through the brain and shows brain-wave activity. It can help diagnose seizures." d."It's a special x-ray that shows structures of the brain and whether there has ever been a brain injury."

B The parent is seeking information about PET scans. It is important to use terms the parent can understand, so the nurse should identify what the initials mean. The correct response is the only option that provides information relevant to PET scans. The distracters describe MRI, CT scans, and EEG. See relationship to audience response question.

46. Pamela has sought treatment for ongoing substance use disorder. She asks the nurse what treatment options are available to help her combat this problem. Which of these options would be accurate for the nurse to include in patient education? Select all that apply. 1) ECT 2) Self-help groups 3) Deterrent therapy 4) Substitution pharmacotherapy 5) Vitamin supplements

Feedback 1: ECT is primarily indicated for the treatment of depression. There is no evidence of its benefit in preventing relapse in substance use disorders. Correct 2: Self-help groups such as Alcoholics Anonymous are commonly recommended as a treatment option for substance use disorders. Correct 3: Deterrent therapy, such as Antabuse to deter alcohol use, is a recognized option for some substance use disorders. Correct 4: Substitution therapy, such as methadone for heroin users, is a recognized option for some substance use disorders. Feedback 5: Vitamin supplements are beneficial in reversing nutritional deficiencies in alcoholism and other substance use disorders but do not combat the problem of substance use disorder itself.

43. The nurse is assessing a client who is a substance abuser. The client states, "I use every day, but it rarely interferes with my work." The nurse determines that the client is using which defense mechanism? 1) Projection 2) Denial 3) Reaction formation 4) Displacement

2) Denial Denial is characterized by avoidance of disagreeable realities and unconscious refusal to acknowledge a thought, feeling, need, or desire. By stating that alcohol use rarely interferes with his or her work, the client is denying a substance abuse problem.

33. Which client and family teaching is most important regarding the cause of substance addiction? 1) An individual's social and cultural environment can be implicated in the cause of substance addiction. 2) Biological, psychological, and sociocultural factors can all be implicated in the cause of substance addiction. 3) Evidence of a genetic link accounts for most cases of substance addiction. 4) Reinforcing properties of the substance encourage progression from use to addiction.

2) Biological, psychological, and sociocultural factors can all be implicated in the cause of substance addiction.

A nurse is concerned that an agency's policies are inadequate. Which understanding about the relationship between substandard institutional policies and individual nursing practice should guide nursing practice? a. Agency policies do not exempt an individual nurse of responsibility to practice according to professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. Faced with substandard policies, a nurse has a responsibility to inform the supervisor and discontinue patient care immediately. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

A

49. A client is diagnosed with stimulant use disorder: cocaine and antisocial personality disorder. The client eagerly participates in therapy and becomes charming and ingratiating to the primary nurse. Which best describes these client behaviors? 1) The client has not completed the cocaine withdrawal process. 2) The client is probably hiding something. 3) The client is exhibiting characteristics of antisocial personality disorder. 4) The client is exhibiting symptoms of cocaine dependence.

3) The client is exhibiting characteristics of antisocial personality disorder.

A person in the community asks, "Why aren't people with mental illness kept in state institutions anymore?" Select the nurse's best response. a. "Less restrictive settings are available now to care for individuals with mental illness." b. "There are fewer persons with mental illness, so less hospital beds are needed." c. "Most people with mental illness are still in psychiatric institutions." d. "Psychiatric institutions violated patients' rights."

A

47. On admission, a client experienced severe alcohol withdrawal symptoms. Four days later, the nurse notes a decrease in withdrawal symptoms. Which nursing intervention is most appropriate? 1) Withhold potentially addictive as needed (prn) medications. 2) Increase prn medications because potentially fatal complications can still occur. 3) Ask the doctor to prescribe a less addictive medication to reduce potential for dependence. 4) Monitor for withdrawal complications and administer medications on the basis of client symptoms.

4) Monitor for withdrawal complications and administer medications on the basis of client symptoms. The nurse must remain vigilant because withdrawal complications can occur days after initial withdrawal symptoms appear. Medication dosages for withdrawal should be based on an objective assessment of symptoms. This is usually done by the use of an assessment tool such as Clinical Institute Withdrawal Assessment (CIWA).

53. A client is brought to the ED. The client is aggressive, has slurred speech, and exhibits impaired motor coordination. Blood alcohol level is 347 mg/dL. Among the physician's orders is thiamine. Which is the rationale for this intervention? 1) To prevent nutritional deficits 2) To prevent pancreatitis 3) To prevent alcoholic hepatitis 4) To prevent Wernicke's encephalopathy

4) To prevent Wernicke's encephalopathy Wernicke's encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. If thiamine replacement therapy is not undertaken quickly, death will ensue.

34. Which symptom would the nurse expect to observe in a client experiencing opioid intoxication? 1) Insomnia 2) Abdominal cramps 3) Muscle aches 4) Impaired judgment

4) Impaired judgment Impaired judgment; initial euphoria followed by apathy; dysphoria; and psychomotor agitation or retardation are all symptoms of opioid intoxication.

10. Which should the nurse recognize as an example of localized amnesia? A. A client cannot relate any lifetime memories, including personal identity. B. A client can relate family memories but has no recollection of a particular brother. C. A client cannot remember events surrounding a fatal car accident. D. A client whose home was destroyed by a tornado only remembers waking up in the hospital.

ANS: C An individual with localized amnesia is unable to recall all incidents associated with a stressful event.

44. Janice is a nurse whose husband is in rehab for alcohol use disorder. While attending a family group, Janice makes several statements about their relationship. Which of these statements would suggest Janice is exhibiting codependent behavior? Select all that apply. 1) "My husband has to accept responsibility for his behavior and the consequences of his drinking." 2) "I know I shouldn't go out drinking with him, but I'm afraid he'll leave me if I don't." 3) "My father was the same way and I learned its better just to keep your mouth shut so you don't get hit." 4) "If he didn't have me monitoring his every move he'd probably be dead already." 5) "I need to make sure I'm protecting myself and my children."

Feedback 1: This statement is an example of healthy boundaries rather than codependent behavior. Correct 2: People-pleasing, fear of abandonment, and neediness, as evidenced in this statement, are all characteristic codependent behaviors. Correct 3: The sense of helplessness and a history of abuse or neglect as a child are consistent with codependency. Correct 4: This statement suggests an unrealistic need to be in control and may also suggest that Janice's self-worth is rooted in her need to be needed. Both of these are evidence of codependency. Feedback 5: Janice's expression of concern for her own safety and her clear identification of her responsibilities as a parent are examples of healthy rather than codependent behaviors.

18. An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

a. Dementia

While talking with a patient diagnosed with major depression, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest, while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills

ANS: A Eye contact and body movements are considered nonverbal communication. There are insufficient data to determine the level of the patient's social skills or whether a cultural barrier exists.

8. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem? a. Major depressive disorder b. Bipolar disorder c. Schizophrenia d. Dementia

ANS: A Major depressive disorder frequently co-occurs with PTSD. The incidence of the disorders identified in the distractors is similar to the general population.

38. A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

ANS: A Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

11. Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which nursing care should be included for this client? A. Deal with physical symptoms in a detached manner. B. Challenge the validity of physical symptoms. C. Meet dependency needs until the physical limitations subside. D. Encourage a discussion of feelings about the lower-extremity problem.

ANS: A The nurse should assist the client in dealing with physical symptoms in a detached manner to avoid reinforcing the symptoms by providing secondary gains. This is an example of a conversion disorder in which symptoms affect voluntary motor or sensory functioning. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations.

2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

ANS: A, B, C, D Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder. REF: Page 459-460 | Page 465-466

19. A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety.

A patient becomes frustrated and angry and when trying to get hi MP3 player and headset to function properly and angrily throws it across the room, nearly hitting a peer with it. Which interventions would be the most therapeutic. Select all that apply. a. place the pt in seclusion for an hour to allow him to deescalate b. tell the pt that any further outbursts will result in a loss of privileges c. offer to help the pt learn how to operate his music player and headset d. explore with the pt how he was feeling as he worked with the music player e. point out the consequences of such behavior and note that it cannot be tolerated f. limit the pts exposure to frustrating experiences until he attains improved coping skills g. encourage the pt to recognize signs of escalating tension and seek assistance

ANS: A,D,E,G

Insurance will not pay for continued private hospitalization of a mentally ill patient. The family considers transferring the patient to a public hospital but expresses concern that the patient will not get any treatment if transferred. Select the nurse's most helpful reply. a. "By law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse." c. "You have a justifiable concern because the right to treatment extends only to provision of food, shelter, and safety." d. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable."

A

The nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which effect would be expected? a. Reduced anxiety b. Improved memory c. More organized thinking d. Fewer sensory perceptual alterations

A Increased levels of GABA reduce anxiety. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

A drug causes muscarinic receptor blockade. The nurse will assess the patient for: a. dry mouth b. gynecomastia c. pseudoparkinsonism d. orthostatic hypotension

A Muscarinic receptor blockade includes atropine-like side effects, such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with 1 antagonism.

The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3. Select the nurse's best action. a. Report the results to the health care provider immediately. b. Administer the next dose as prescribed. c. Give aspirin and force fluids. d. Repeat the laboratory test.

A These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider, and the drug should be withheld. The health care provider may repeat the test, but in the meantime, the drug should be withheld. Caution: This question requires students to apply previous learning regarding normal and abnormal values of white blood cell counts.

12. Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's Disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. is rarely helpful. b. fosters independence. c. lifts the burden of personal decision making. d. helps the patient develop feelings of personal adequacy.

ANS: A Giving advice fosters dependence on the nurse and interferes with the patient's right to make personal decisions. It robs patients of the opportunity to weigh alternatives and develop problem-solving skills. Furthermore, it contributes to patient feelings of personal inadequacy. It also keeps the nurse in control and feeling powerful.

17. A nurse talks with the caregiver of a combat veteran diagnosed with severe traumatic brain injuries. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Select the nurse's best response. a. "How are you taking care of yourself?" b. "Let's review your partner's diagnostic results." c. "I have some web-based programs for you to visit." d. "Your partner is lucky to have someone so devoted."

ANS: A The caregiver is the focus of the nurse's attention. The caregiver is suffering. The nurse must be empathetic and assess how the caregiver is caring for self. Reassurance and isolated computer activities do not help. The partner is already aware of the diagnostic results.

21. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

2. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)

ANS: A, B, E Standardized scales are useful for obtaining data about substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. AIMS assesses involuntary movements associated with anti-psychotic medications. The CCSE assesses cognitive function.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

7. Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

18. During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.

5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

ANS: B The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

19. Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.

Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

36. Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

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.

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

ANS: C The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity. REF: Page 465-466

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.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

1. A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation

ANS: C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommate's absence from the dormitory. Terminating access to one's social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness.

A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

ANS: C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Patients are observed during and after meals to prevent throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

Annie is extremely underweight and disappears into the bathroom after meals, angrily says to the nurse, "I don't need to be here. I don't have any problems. Stop watching me." To reduce her feeling of being threatened, the nurse would be most therapeutic by responding: A. "Your feelings are part of your illness; later you will feel better." B. "I'll get your medication your physician ordered for anxiety." C. "If you do not follow the rules, you will lose your privileges." D. "I hear how frustrated you are to be here."

ANS: D

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine (Clozaril) b. Ziprasidone (Geodon) c. Olanzapine (Zyprexa) d. Aripiprazole (Abilify)

ANS: D Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying: a. "Why do you keep asking about me?" b. "Nurses direct the interviews with patients." c. "Do not ask questions about my personal life." d. "The time we spend together is to discuss your concerns."

ANS: D When a patient tries to focus on the nurse, the nurse should refocus the discussion back onto the patient. Telling the patient that interview time should be used to discuss patient concerns refocuses discussion in a neutral way. Telling patients not to ask about the nurse's personal life shows indignation. Saying that nurses prefer to direct the interview reflects superiority. "Why" questions are probing and non-therapeutic.

Which nursing intervention below is part of the scope of an advanced practice psychiatric/mental health nurse only? a. Coordination of care b. Health teaching c. Milieu therapy d. Psychotherapy

ANS: D Psychotherapy is part of the scope of practice of an advanced practice nurse. The distracters are within a staff nurse's scope of practice.

The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Integumentary d. Cardiovascular

ANS: D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patient's physiological integrity. The other body systems are not initially involved in refeeding syndrome.

3. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Posttrauma response c. Disturbed thought processes d. Risk for other-directed violence

ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

16. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are most important and which are less important."

ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should: a. review the directive with the patient to ensure it is current. b. ensure that the directive is respected in treatment planning. c. consider the directive only if there is a cardiac or respiratory arrest. d. encourage the patient to revise the directive in light of the current health problem.

B

A nurse caring for a patient taking a selective serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. coherent thought processes b. improvement in depression c. reduced levels of motor activity d. decreased extrapyramidal symptoms

B SSRIs affect mood, relieving depression in many cases. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more than the usual geriatric dose. The nurse should: a. consult a reliable drug reference. b. teach the patient about possible side effects and adverse effects. c. withhold the medication and confer with the health care provider. d. encourage the patient to increase oral fluids to reduce drug concentration.

C

Which individual diagnosed with a mental illness may need involuntary hospitalization? An individual: a. who has a panic attack after her child gets lost in a shopping mall b. with visions of demons emerging from cemetery plots throughout the community c. who takes 38 acetaminophen tablets after the person's stock portfolio becomes worthless d. diagnosed with major depression who stops taking prescribed antidepressant medication

C

A nurse can anticipate anticholinergic side effects are likely when a patient takes: a. lithium (Lithobid) b. buspirone (BuSpar) c. imipramine (Tofranil) d. risperidone (Risperdal)

C Imipramine (Tofranil) is a tricyclic antidepressant with strong anticholinergic properties, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid-balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.

55. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you began feeling depressed."

a. "Are you having thoughts of suicide?"

13. A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

a. History of family violence

19. An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision

39. An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

a. maintaining the airway.

47. An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

b. "Do you have access to medications?"

34. Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision.

52. Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment

b. Attending a self-help group for survivors

1. A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

b. Child and siblings are experiencing neglect.

5. A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

b. Have the patient fill out an abuse assessment screen.

6. A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

b. Risk of domestic abuse

57. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

c. Availability of means and lethality of method

2. An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional

14. An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

c. Honeymoon

17. An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

c. Physical

44. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen

c. Risk for suicide

8. Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

c. bite marks

50. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

c. establish a rapport with the patient.

56. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are most important and which are less important." d. "Let's consider which problems are most important and which are less important."

d. "Let's consider which problems are most important and which are less important."

24. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

d. Denial

12. An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

d. Document injuries with a body map.

10. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

d. Physical injuries

22. A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

d. Severe

58. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

d. experiencing hopelessness.

ego

our sense of self and acts as an intermediary between the id and the world

Cognitive theory

theorist: Beck Tenet(principle or belief): negative and self-critical thinking causes depression Therapeutic model: cognitive behavioral therapists assist in identifying negative thoughts patterns and replacing them with rational ones

After formulating the nursing diagnoses for a new patient, what is a nurse's next action? a. Designing interventions to include in the plan of care b. Determining the goals and outcome criteria c. Implementing the nursing plan of care d. Completing the spiritual assessment

ANS: B The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and nursing diagnoses have been formulated.

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient's hand. Select the correct analysis of the nurse's behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Psychiatric patients should not be touched.

ANS: B Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the patient will perceive touch. The other options present prematurely drawn conclusions.

27. An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." Which response is the nurse demonstrating? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

ANS: B Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view of the world.

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

25. A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

20. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.

ANS: B Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse's presence and concerns. The incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

1. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as: a. denial. b. splitting. c. defensive. d. reaction formation.

ANS: B Splitting involves loving a person, then hating the person because the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness. See relationship to audience response question. REF: Page 463 (Table 24 - 2) | Page 470-471

12. Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessment

ANS: B Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide.

A nurse encounters an unfamiliar psychiatric disorder on a new patient's admission form. Which resource should the nurse consult to determine criteria used to establish this diagnosis? a. International Statistical Classification of Diseases and Related Health Problems (ICD-10) b. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) c. A behavioral health reference manual d. Wikipedia

ANS: B The DSM-5 gives the criteria used to diagnose each mental disorder. The distracters may not contain diagnostic criteria for a psychiatric illness.

23. A patient with burn injuries has had good coping skills for several weeks. Today, a newly assigned nurse is poorly organized. The patient's usual schedule was not followed. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization, and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

ANS: B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patient's feelings, validating them as understandable, apologizing as necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

10. An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.

11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

9. Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiological intervention.

ANS: C Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health education needs and giving information about these needs. Psychobiological interventions involve medication administration and monitoring response to medications.

15. Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

5. A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

ANS: C Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patient's feelings and concerns, which leads to the next step of planning an intervention.

A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response? a. "Why are you asking me when you're able to speak for yourself?" b. "I will be glad to address it when I see your doctor later today." c. "That's a good topic for you to discuss with your doctor." d. "Do you think you can't speak to a doctor?"

ANS: C Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency.

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

6. An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority? A. Encourage exploration of sexual abuse B. Encourage guided imagery C. Establish trust and rapport D. Administer antianxiety medications

ANS: C The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with dissociative identity disorder. DID was formerly called multiple personality disorder. Each personality views itself as a separate entity and must be treated as such to establish rapport. Trust is the basis of every therapeutic relationship.

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.

3. Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

3. A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Post-traumatic stress disorder

ANS: C, E TBI and PTSD each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population.

4. A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Post-traumatic stress disorder

ANS: C, E Traumatic brain injury and post-traumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population.

Katrina is a 15 year-old client who stands 5-foot, 5-inch-tall, and weighs 80 pounds. She is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes that her problem most likely is caused by: A. A delusion in which she believes she must be thin B. The media's emphasis on the beauty of thinness C. The wish to be accepted by her peers D. A desire to control her life

ANS: D

Lacey, a 19 year old, shows you multiple fresh, serious (but non life threatening) self-inflicted cuts on her forearms. Which response would bet he most therapeutic? a. im so sorry you felt so bad that you cut yourself lets discuss what led up to this action while i take care of your wounds b. i will take care of your wounds first then you will have to be searched for anything else you could injure yourself with c. i can give you some bandaids for you to put on your cuts, but you need to stop this attention seeking behavior d. after i care for your wounds i would like you to write down what you were feeling and thinking before you cut yourself. then we will discuss it.

ANS: D

A nurse interacts with a newly hospitalized patient. Select the nurse's comment that applies the communication technique of "offering self." a. "I've also had traumatic life experiences. Maybe it would help if I told you about them." b. "Why do you think you had so much difficulty adjusting to this change in your life?" c. "I hope you will feel better after getting accustomed to how this unit operates." d. "I'd like to sit with you for a while to help you get comfortable talking to me."

ANS: D "Offering self" is a technique that should be used in the orientation phase of the nurse-patient relationship. Sitting with the patient, an example of "offering self," helps to build trust and convey that the nurse cares about the patient. Two incorrect responses are ineffective and non-therapeutic. The other incorrect response is therapeutic but is an example of "offering hope."

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as: a. consistently demonstrated. b. often demonstrated. c. sometimes demonstrated. d. never demonstrated.

ANS: D Although the patient is sleeping 6 hours daily, the total is not one uninterrupted session at night. Therefore, the outcome must be evaluated as never demonstrated. See relationship to audience response question.

A Puerto Rican American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient's behavior? The patient: a. has a histrionic personality disorder. b. believes dramatic body language is sexually appealing. c. wishes to impress staff with the degree of emotional pain. d. belongs to a culture in which dramatic body language is the norm.

ANS: D Members of Hispanic American subcultures tend to use high affect and dramatic body language as they communicate. The other options are more remote possibilities.

A school age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response. a. "Just ignore them and they will leave you alone." b. "You should make friends with other children." c. "Call them names if they do that to you." d. "Tell me more about how you feel."

ANS: D The correct response uses exploring, a therapeutic technique. The distracters give advice, a non-therapeutic technique.

At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of: a. childhood growth and development b. substance use and abuse c. educational background d. coping strategies

ANS: D When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient's faith helps deal with stress fits well here. It would be out of place if introduced during exploration of the other topics.

Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Blood pressure 78/58 mm Hg

ANS: D Blood pressure less than 90/60 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hr. A potassium level of 3.4 mEq/L is within the normal range.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

A patient diagnosed with schizophrenia believes a local minister stirred evil spirits. The patient threatens to bomb a local church. The psychiatrist notifies the minister. Select the answer with the correct rationale. The psychiatrist: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.

B

An aide in a psychiatric hospital says to the nurse, "We don't have time every day to help each patient complete a menu selection. Let's tell dietary to prepare popular choices and send them to our unit." Select the nurse's best response. a. "Thanks for the suggestion, but that idea may not work because so many patients take MAOI (monoamine oxidase inhibitor) antidepressants." b. "Thanks for the idea, but it's important to treat patients as individuals. Giving choices is one way we can respect patients' individuality." c. "Thank you for the suggestion, but the patients' bill of rights requires us to allow patients to select their own diet." d. "Thank you. That is a very good idea. It will make meal preparation easier for the dietary department."

B

Select the example of a tort. a. The plan of care for a patient is not completed within 24 hours of the patient's admission. b. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short-staffed. c. An advanced practice nurse recommends hospitalization for a patient who is dangerous to self and others. d. A patient's admission status changed from involuntary to voluntary after the patient's hallucinations subside.

B

An individual hiking in the forest encounters a large poisonous snake on the path. Which change in this individual's vital signs is most likely? a. Pulse rate changes from 90 to 72. b. Respiratory rate changes from 22 to 18. c. Complaints of intestinal cramping begin. d. Blood pressure changes from 114/62 to 136/78.

D This frightening experience would stimulate the sympathetic nervous system, causing a release of norepinephrine, an excitatory neurotransmitter. It prepares the body for fight or flight. Increased blood pressure, pupil size, respiratory rate, and pulse rate signify release of norepinephrine. Intestinal cramping would be associated with stimulation of the parasympathetic nervous system.

Freud identified three layers of mental activity:

The conscious preconscious unconscious

23. A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

a. Confusion and disbelief

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

b. Strong negative feelings interfere with assessment and judgment.

21. A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator

b. Survivor

27. A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

d. Support the victim to separate issues of vulnerability from blame.

45. Which primary factor is critical in maintaining abstinence for the client diagnosed with alcohol use disorder? 1) Attendance at Alcoholics Anonymous (AA) meetings 2) Personal commitment to change 3) Family involvement 4) Compliance with pharmacological therapy

2) Personal commitment to change The first step in the recovery process necessitates that the client accept ownership of the problem and establish a behavioral change commitment to continued abstinence.

50. A client diagnosed with chronic alcohol use disorder complains of feeling tremulous. The client's BP is now 170/110, P 116, R 30, T 97°F. The nurse anticipates which medication would give the client the most immediate relief from these symptoms? 1) Benztropine (Cogentin), 2 mg PO 2) Oxazepam (Serax), 30 mg PO 3) Lorazepam (Ativan), 1 mg IM 4) Meperidine (Demerol), 100 mg IM

3) Lorazepam (Ativan), 1 mg IM Ativan is frequently used to treat the symptoms of alcohol withdrawal. Because Ativan is ordered parenterally, this medication would give the client the most immediate relief of symptoms.

One bed is available on the inpatient eating disorders unit. The patient with which of the following weight decrease should be admitted to this bed? a. From 70 to 45 kg over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. From 55 to 40 kg over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. From 50 to 32 kg over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. From 40 to 35 kg over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

ANS: A Physical criteria for hospitalization include weight loss less than 85% of ideal weight or rapid decline in weight and food refusal, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and blood pressure less than 90/60 mm Hg.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

6. A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

ANS: A The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario.

A patient referred to the eating disorders clinic has lost 16 kg in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia. See relationship to audience response question.

A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances

ANS: B Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of "Call my doctor" if the patient's cognition and judgment are intact. If the patient responds, "I would stop eating" or "I would just wait and see what happened," the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

2. A patient diagnosed with liver failure has been on the transplant waiting list 8 months. The patient says, "Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done." The nurse should document the patient's comment in which section of the assessment? a. Physical b. Spiritual c. Financial d. Psychological

ANS: B Stress can be evident in a person's spirituality. This patient's comment indicates questioning of one's place in the universe and consequences for wrongdoing, both of which are elements of spirituality. Stress can be related to psychological, physical, or psychosocial well-being, but spirituality is the best answer.

11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake.

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relate to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention.

A patient referred to the eating disorders clinic has lost 15 kg during the past 3 months. To assess eating patterns, which of the following should the nurse should ask the patient? a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

ANS: C Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination

ANS: C During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

Which comments by a nurse demonstrate use of therapeutic communication techniques? Select all that apply. a. "Why do you think these events have happened to you?" b. "There are people with problems much worse than yours." c. "I'm glad you were able to tell me how you felt about your loss." d. "I noticed your hands trembling when you told me about your accident." e. "You look very nice today. I'm proud you took more time with your appearance."

ANS: C, D The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate minimizing feelings, probing, and giving approval, which are non-therapeutic techniques.

A nurse is part of a multidisciplinary team working with groups of depressed patients. Half the patients receive supportive interventions and antidepressant medication. The other half receives only medication. The team measures outcomes for each group. Which type of study is evident? a. Incidence b. Prevalence c. Co-morbidity d. Clinical epidemiology

ANS: D Clinical epidemiology is a broad field that addresses studies of the natural history (or what happens if there is no treatment and the problem is left to run its course) of an illness, studies of diagnostic screening tests, and observational and experimental studies of interventions used to treat people with the illness or symptoms. Prevalence refers to numbers of new cases. Co-morbidity refers to having more than one mental disorder at a time. Incidence refers to the number of new cases of mental disorders in a healthy population within a given period. See related audience response question.

23. A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

Which of the following are true of antisocial personality disorder (APD)? (select all that apply): a. It is the least studied of the personality disorders. b. It is characterized by rigidity and inflexible standards of self and others. c. Persons with APD display magical thinking. d. Persons with APD are concerned with personal pleasure and power. e. It is characterized by deceitfulness, disregard for others, and manipulation. f. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. g. Frontal lobe dysfunction is a brain change identified in APD.

ANS: D,E,G

What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse: a. has been negligent. b. committed malpractice. c. fulfilled the standard of care. d. can be charged with battery.

D

9. An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

a. Chronic low self-esteem, related to negative feedback from parents

60. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.

a. hopelessness.

36. A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase

b. Acute phase

38. A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

b. provide written information concerning the physical and emotional reactions that may be experienced.

52. A client is being discharged from an alcohol treatment program. The client's wife states, "I'm so afraid that when my husband leaves here, he'll relapse. How can I deal with this?" Which nursing statement would be most appropriate? 1) "Many family members of alcoholics find the Al-Anon support group to be helpful." 2) "You could try going out and having a few beers with him when he gets the urge to drink." 3) "Just make sure he doesn't drink at home. Find all of his hidden bottles and empty them." 4) "Tell your husband that if he drinks again, you will leave him."

1) "Many family members of alcoholics find the Al-Anon support group to be helpful." Al-Anon is a nonprofit organization that provides group support for the family and close friends of alcoholics.

In order to release information to another health care facility or third party regarding a patient diagnosed with a mental illness, the nurse must obtain: a. a signed consent by the patient for release of information stating specific information to be released. b. a verbal consent for information release from the patient and the patient's guardian or next of kin. c. permission from members of the health care team who participate in treatment planning. d. approval from the attending psychiatrist to authorize the release of information.

A

Which of the following contributions to modern psychiatric nursing practice was made by Freud? A. The theory of personality structure and levels of awareness B. The concept of a "self-actualized personality" C. The thesis that culture and society exert significant influence on personality D. Provision of a developmental model that includes the entire life span

A. The theory of personality structure and levels of awareness

The nurse recognizes that the most specific signs and symptoms for diagnosing anorexia nervosa are: A. Excessive weight loss, amenorrhea, and abdominal distention B. Excessive activity, memory lapses, and an increase pulse C. Compulsive behaviors, excessive fears, and nausea D. Slow pulse, mild weight loss, and alopecia

ANS: A

2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a. "This patient continues to deny problems resulting from drinking." b. "My parents were alcoholics and often neglected our family." c. "The patient cannot identify any goals for improvement." d. "The patient said I have many traits like her mother."

ANS: B Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse's irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient's behavior.

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. self-responsibility and autonomy. b. a greater sense of independence. c. rapport and trust with the nurse. d. resolved transference.

ANS: C Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase.

2. A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go.

4. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.

Which belief will best support a nurse's efforts to provide patient advocacy during a multidisciplinary patient care planning session? a. All mental illnesses are culturally determined. b. Schizophrenia and bipolar disorder are cross-cultural disorders. c. Symptoms of mental disorders are unchanged from culture to culture. d. Assessment findings in mental disorders reflect a person's cultural patterns.

ANS: D A nurse who understands that a patient's symptoms are influenced by culture will be able to advocate for the patient to a greater degree than a nurse who believes that culture is of little relevance. The distracters are untrue statements.

Which characteristic suggests to the nurse that an adolescent may have bulimia? A. Frequent regurgitation and reswallowing of food B. A positive body image and self-concept C. Previous history of gastritis D. Excessive stained teeth

ANS: D

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive. REF: Page 460-461 | Page 463 (Table 24 - 2)

41. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

b. Serotonin deficiency

32. An impaired nurse is admitted to an inpatient substance abuse treatment facility. Which applies to his situation? 1) The nurse must relinquish his driver's license to the office of motor vehicles. 2) The nurse is mandated to comply with treatment and prescribed therapies. 3) The nurse is not mandated to meet specific requirements, because all civil rights are ensured. 4) The nurse must relinquish his registered nurse (RN) license to the state board of nursing.

3) The nurse is not mandated to meet specific requirements, because all civil rights are ensured. Although some variations occur from state to state, currently psychiatric clients maintain all of their civil rights. This nurse is not mandated by law to meet specific requirements, because all civil rights are ensured.

A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's most therapeutic response? a. "You sound very upset about this." b. "God always forgives us for our sins." c. "Why do you think you are being punished?" d. "If you feel this way, you should talk to your minister."

ANS: A The nurse reflects the patient's comment, a therapeutic technique to encourage sharing for perceptions and feelings. The incorrect responses reflect probing, closed-ended comments, and giving advice, all of which are non-therapeutic.

Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

6. A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder. REF: Page 476 (Fig 24 - 1)

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Which finding best indicates that the goal "Demonstrate mentally healthy behavior" was achieved? A patient: a. sees self as capable of achieving ideals and meeting demands. b. behaves without considering the consequences of personal actions. c. aggressively meets own needs without considering the rights of others. d. seeks help from others when assuming responsibility for major areas of own life.

ANS: A The correct response describes an adaptive, healthy behavior. The distracters describe maladaptive behaviors.

A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse's most caring comment. a. "Let's discuss some means of coping othe b. "I understand why you're so depressed. When I got divorced, I was devastated too." c. "You should forget about your marriage and move on with your life." d. "How did you get so depressed that hospitalization was necessary?"

ANS: A The nurse's communication should evidence caring and a commitment to work with the patient. This commitment lets the patient know the nurse will help. Probing and advice are not helpful or therapeutic interventions.

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe

ANS: A, D The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations.

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-revelation in patient interactions. d. consistently interpret the patient's behaviors.

ANS: B Genuineness is a desirable characteristic involving awareness of one's own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship.

4. A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system is stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

ANS: C The autonomic nervous system is made up of the sympathetic (fight-or-flight response) and parasympathetic (relaxation response) nervous systems. In times of stress, the sympathetic nervous system is stimulated. A person fearful of heights would experience stress associated with the experience of driving across a high bridge. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

18. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."

ANS: C Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness.

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by alien monsters d. Completing alcohol withdrawal and beginning a rehabilitation program

ANS: C The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distracters have better reality-testing ability.

11. A soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. Family outing to the seashore d. Fireworks display on July 4th

ANS: D exploding noises associated with fireworks are most likely to provoke exaggerated responses for this soldier. The distractors are not associated with offensive sounds.

8. A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common. REF: Page 463 (Table 24-2) | Page 465-466 | Page 469 (Table 24-4)

48. A client who is unable to control binge drinking requires increased amounts of alcohol to achieve the same level of intoxication. The client is experiencing marital strife and legal problems. The client's behaviors meet the criteria for which DSM-5 diagnostic category? 1) Dual diagnosis 2) Alcohol use disorder 3) Neurocognitive disorder 4) Alcohol intoxication

2) Alcohol use disorder This client has developed tolerance, cannot control alcohol intake, and has continued use despite persistent problems related to drinking. These symptoms meet the criteria for the diagnosis of alcohol use disorder in the DSM-5.

A patient in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action. a. Anonymously report the abuse by phone to the local child protection agency. b. Reply, "I'm glad you feel comfortable talking to me about it." c. File a written report with the agency's ethics committee. d. Respect nurse-patient relationship confidentiality.

A

The nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the: a. Parasympathetic nervous system b. Sympathetic nervous system c. Reticular activating system d. Medulla oblongata

A Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When anticholinergic drugs inhibit acetylcholine action, blurred vision, dry mouth, constipation, and urinary retention commonly occur.

An obese patient has a diagnosis of schizophrenia. Medications that block which receptors would contribute to further weight gain? a. H1 b. Acetylcholine c. 5 HT2 d. Gamma-aminobutyric acid (GABA)

A H1 receptor blockade results in weight gain, which is undesirable for an obese patient. Blocking of the other receptors would have little or no effect on the patient's weight.

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. With which patient should the nurse be most alert for problems associated with fluid and electrolyte imbalance? The patient receiving: a. lithium (Lithobid) b. clozapine (Clozaril) c. fluoxetine (Prozac) d. venlafaxine (Effexor)

A Lithium is a salt and known to alter fluid and electrolyte balance, producing polyuria, edema, and other symptoms of imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block. Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.

A nurse prepares to administer a second-generation antipsychotic medication to a patient diagnosed with schizophrenia. Additional monitoring for adverse effects will be most important if the patient has which co-morbid health problems? Select all that apply. a. Parkinson's disease b. Grave's disease c. Hyperlipidemia d. Osteoarthritis e. Diabetes

A, C, E Antipsychotic medications may produce weight gain, which would complicate care of a patient with diabetes, and increase serum triglycerides, which would complicate care of a patient with hyperlipidemia. Parkinson's disease involves changes in transmission of dopamine and acetylcholine, so these drugs would also complicate care of this patient. Osteoarthritis and Grave's disease should have no synergistic effect with this medication.

According to Maslow's Hiearchy of Needs, the most basic needs for psychiatric mental health nursing are: A. Psychological B. Safety C. Love and Belonging D. self-actualization

A. Psychological

The nurse is caring for a patient with bulimia. Which nursing intervention is appropriate? 1. Monitor patient on bathroom trips after eating. 2. Allow patient extensive private time with family members. 3. Provide meals whenever the patient requests them. 4. Encourage patient to select foods that she or he likes.

ANS: 1 1. Close observation of patients includes monitoring all trips to the bathroom after eating to prevent self-induced vomiting. 2. Although family contact is important, extensive family time would interfere with the patient participating in the therapeutic activities on the unit. The milieu of an eating-disorder unit is purposefully organized to assist the patient in establishing more adaptive behavioural patterns, including normalization of eating. 3. Providing meals whenever the patient requests them is not consistent with the normalization of eating. The highly structured milieu includes precise mealtimes, adherence to the selected menu, observation during and after meals, and regularly scheduled weigh-ins. 4. Encouraging the patient to select foods that she likes does not support the normalization of eating and may not meet all the patient's daily nutritional requirements.

The nurse is planning care for a patient with an eating disorder. What outcomes are appropriate Select all that apply. 1. The patient will experience a decrease in depression. 2. The patient will identify 4 methods to control anxiety. 3. The patient will collect different kinds of cookbooks. 4. The patient will identify 2 people to contact if suicidal thoughts occur.

ANS: 1,2,4 1. Patients with eating disorders are very likely to have depression, anxiety, higher suicide rates, and problems with substance abuse. Therefore, decreasing depression, controlling anxiety, and having a support system in place are reasonable outcomes for planning care. 2. Patients with eating disorders are very likely to have depression, anxiety, higher suicide rates, and problems with substance abuse. Therefore, decreasing depression, controlling anxiety, and having a support system in place are reasonable outcomes for planning care. 3. Hoarding items, especially cookbooks, is often associated with the co-morbid condition of obsessive-compulsive disorder (OCD) and should not be encouraged. 4. Patients with eating disorders are very likely to have depression, anxiety, higher suicide rates, and problems with substance abuse. Therefore, decreasing depression, controlling anxiety, and having a support system in place are reasonable outcomes for planning care.

The nurse is admitting a patient who weighs 45 kg, is 167 cm tall, and is below ideal body weight. The patient's BP is 130/80, pulse 72 bpm, potassium 2.5 mmol/L, and ECG is abnormal. Her teeth enamel is eroded, her hands are visibly shaking, and her parotid gland is enlarged. The patient states, "I am really worked up about coming to this unit." What is the priority nursing diagnosis? 1. Powerlessness 2. Risk for injury 3. Imbalanced nutrition: Less than body requirements. 4. Anxiety

ANS: 2 1. Although Powerlessness is an appropriate nursing diagnosis, it is not the priority diagnosis. 2. Although all diagnoses listed are appropriate to consider within the plan of care, the priority is Risk for injury related to the low potassium value, mildly elevated blood pressure, and abnormal ECG, which indicates hypokalemia. If left untreated, multiple complications— including cardiac arrhythmias and eventual respiratory depression—can occur. 3. Although Imbalanced nutrition: Less than body requirements is an appropriate nursing diagnosis, it is not the priority diagnosis. 4. Although Anxiety is an appropriate nursing diagnosis, it is not the priority diagnosis.

The nurse is caring for a 16 year old female patient with anorexia nervosa. What should the initial nursing intervention be upon the patient's admission to the unit? 1. Build a therapeutic relationship. 2. Increase the patient's caloric consumption. 3. Involve the patient in group therapy to build a support group. 4. Self-assess to decrease tendencies toward authoritarianism.

ANS: 4 1. For the duration of the patient's stay, building a therapeutic relationship will be important, but it is not the initial nursing intervention. 2. For the duration of the patient's stay, having a plan to increase the patient's caloric consumption will be important, but it is not the initial nursing intervention. 3. For the duration of the patient's stay, involving the patient in group therapy to build a support network will be important, but it is not the initial nursing intervention. 4. Without self-assessing, the nurse may inadvertently blame the patient for her health problems and assume a parental role rather than a therapeutic one. The nurse must first self-assess to become aware of personal feelings about the patient's condition and then proceed to act in a therapeutic manner.

Which is true of pharmacological therapies for treatment of personality disorders? a. Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. b. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. c. Patients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors. d. Patients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these patients.

ANS: A

29. A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

6. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

17. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia c. amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

28. An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

18. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

25. An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem.

16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

A patient diagnosed with major depression has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority? a. Implement suicide precautions. b. Offer high-calorie snacks and fluids frequently. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

ANS: A Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication. a. "I notice you keep looking toward the door." b. "This is our time together. No one is going to interrupt us." c. "It looks as if you are eager to end our discussion for today." d. "If you are uncomfortable in this room, we can move someplace else."

ANS: A Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.

14. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

Which technique will best communicate to a patient that the nurse is interested in listening? a. Restating a feeling or thought the patient has expressed. b. Asking a direct question, such as "Did you feel angry?" c. Making a judgment about the patient's problem. d. Saying, "I understand what you're saying."

ANS: A Restating allows the patient to validate the nurse's understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse-patient relationship. Close-ended questions such as "Did you feel angry?" ask for specific information rather than showing understanding. When the nurse simply states that he or she understands the patient's words, the patient has no way of measuring the understanding.

26. A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

13. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option; yet, important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

14. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and now I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind." Which phenomenon associated with post-traumatic stress disorder (PTSD) is this soldier describing? a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: A Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with re-experiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

18. A professor's 4-year-old child has a fever of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which nursing diagnosis best applies to this scenario? a. Decisional conflict b. Unilateral neglect c. Disabled family coping d. Ineffective management of the therapeutic regimen

ANS: A The caregiver is the focus of the nurse's attention. The professor is under stress, related to the conflict between his parenting and professional roles. This scenario presents a decisional conflict. No evidence suggests that family coping is disabled or that a therapeutic regimen is not managed. Unilateral neglect refers to the awareness of the body.

20. Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium.

13. A nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)? a. After a fall, vehicle crash, or exposure to a blast b. Before departing Afghanistan to return to the United States c. One year after returning to the United States from Afghanistan d. Immediately upon return to the United States from Afghanistan

ANS: A The military estimates that up to 20% of the combat veterans in both Afghanistan and Iraq suffer some degree of TBI. TBI exhibits signs shortly after the injury, and these signs usually resolve in days or weeks. Screening after an exposure to an explosion and before returning to the United States is important.

When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate? a. The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The patient is trying to manipulate the nurse using nonverbal techniques.

ANS: A The most likely answer is that the patient's behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are less likely.

12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer.

When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. "Are you having difficulty hearing when I speak?" b. "How can I make this assessment interview easier for you?" c. "I notice you are frowning. Are you feeling annoyed with me?" d. "You're having trouble focusing on what I'm saying. What is distracting you?"

ANS: A The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

22. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

A patient who immigrated to the United States from Honduras was diagnosed with schizophrenia. The patient took an antipsychotic medication for 3 weeks but showed no improvement. Which resource should the treatment team consult for information on more effective medications for this patient? a. Clinical algorithm b. Clinical pathway c. Clinical practice guideline d. International Statistical Classification of Diseases and Related Health Problems (ICD)

ANS: A A clinical algorithm is a guideline that describes diagnostic and/or treatment approaches drawn from large databases of information. These guidelines help the treatment team make decisions cognizant of an individual patient's needs, such as ethnic origin, age, or gender. A clinical pathway is a map of interventions and treatments related to a specific disorder. Clinical practice guidelines summarize best practices about specific health problems. The ICD classifies diseases.

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 patient says, "Please don't share information about me with the other people." How should the nurse respond?* a. "I will not share information with your family or friends without your permission, but I share information about you with other staff." b. "A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know." c. "It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others." d. "I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."

ANS: A A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered.

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.

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship? a. Begin at the orientation phase. b. Resume the working relationship. c. Initially establish a social relationship. d. Return to the emotional catharsis phase.

ANS: A After termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

11. Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.

ANS: A Anger has a strong cognitive component; therefore using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

13. Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

ANS: A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. a. "How do you feel about that?" b. "I am glad that you realize this." c. "That's not a good way to behave." d. "Have you outgrown that type of behavior?"

ANS: A Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal."

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

2. Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority. REF: Page 463 (Table 24-2) | Page 465 | Page 469 (Table 24-4)

Which of the following statements is true of bulimia? A) Patients with bulimia often appear at a normal weight. B) Patients with bulimia binge eat but do not engage in compensatory measures. C) Patients with bulimia severely restrict their food intake. D) One sign of bulimia is lanugo.

ANS: A Patients with bulimia are often at or close to ideal body weight and do not appear physically ill. The other options do not refer to bulimia but rather refer to signs of binge eating disorder and anorexia nervosa.

21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

ANS: A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse. REF: Page 458-459 | Page 463 (Table 24 - 2)

Physical assessment of a patient diagnosed with bulimia often reveals which of the following: a. Prominent parotid glands b. Peripheral edema c. Thin, brittle hair d. Twenty-five percent underweight

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

12. The family of a client diagnosed with conversion disorder asks the nurse, "Will his paralysis ever go away?" Which of these responses by the nurse is evidence-based? A. "Most symptoms of conversion disorder resolve within a few weeks." B. "Typically people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives." C. "The only people who recover are those that develop conversion disorder symptoms without a precipitating stressful event." D. "Technically, he could walk now since he is intentionally feigning paralysis."

ANS: A The evidence supports that most conversion disorder symptoms resolve within a few weeks, and about 20% will have a relapse within 1 year.

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.

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? a. Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates policies of the facility. Decline the card. c. Acknowledge the patient's transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

ANS: A The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient's expression of gratitude.

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

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 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.

At what point in the nurse-patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic

ANS: A The patient has a right to know the conditions of the nurse-patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase.

14. A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

ANS: A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental. REF: Page 465-466

8. An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated.

2. A nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should a nurse expect to assess? A. Disproportionate and persistent thoughts about the seriousness of one's symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms

ANS: A The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues.

In the majority culture of the United States, which individual has the greatest risk to be labeled mentally ill? One who: a. describes hearing God's voice speaking. b. is usually pessimistic but strives to meet personal goals. c. is wealthy and gives away $20 bills to needy individuals. d. always has an optimistic viewpoint about life and having own needs met.

ANS: A The question asks about risk. Hearing voices is generally associated with mental illness, but in charismatic religious groups, hearing the voice of God or a prophet is a desirable event. Cultural norms vary, which makes it more difficult to make an accurate diagnosis. The individuals described in the other options are less likely to be labeled mentally ill.

28. The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications.

27. A new nurse says to a peer, "My newest patient is diagnosed with schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful? a. "Let's reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia." b. "Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs." c. "Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia."

ANS: A Up to 10% of patients diagnosed with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients diagnosed with schizophrenia. Patients diagnosed with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia.

9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

ANS: A Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When patients with antisocial personality disorders use denial, they use it effectively. REF: Page 465-467 (Table 24-3)

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 3.5 kg. The nurse should do which of the following? a. Assess lung sounds and extremities b. Suggest use of an aerobic exercise program c. Positively reinforce the patient for the weight gain d. Establish a higher goal for weight gain the next week

ANS: A Weight gain of more than 2.25 kg in 1 week may result in pulmonary edema. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

A bill introduced in Congress would reduce funding for the care of people diagnosed with mental illnesses. A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? a. Advocacy b. Attending c. Recovery d. Evidence-based practice

ANS: A An advocate defends or asserts another's cause, particularly when the other person lacks the ability to do that for him or herself. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the individuals with mental illness; the letter-writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs.

A nurse says, "When I was in school, I learned to call upset patients by name to get their attention; however, I read a descriptive research study that says that this approach does not work. I plan to stop calling patients by name." Which statement is the best appraisal of this nurse's comment? a. One descriptive research study rarely provides enough evidence to change practice. b. Staff nurses apply new research findings only with the help from clinical nurse specialists. c. New research findings should be incorporated into clinical algorithms before using them in practice. d. The nurse misinterpreted the results of the study. Classic tenets of practice do not change.

ANS: A Descriptive research findings provide evidence for practice but must be viewed in relation to other studies before practice changes. One study is not enough. Descriptive studies are low on the hierarchy of evidence. Clinical algorithms use flowcharts to manage problems and do not specify one response to a clinical problem. Classic tenets of practice should change as research findings provide evidence for change.

4. A professor's 4-year-old child has a temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? Select all that apply. a. Telephoning a grandparent to stay with the child at home for the day. b. Telephoning a colleague to teach his classes and staying home with the sick child. c. Taking the child to the university and keeping the child in a private office for the day. d. Taking the child to a daycare center and hoping daycare workers will not notice the child is sick. e. Giving the child one dose of ibuprofen (Motrin) and taking the child to the daycare center.

ANS: A, B The correct responses demonstrate fulfillment of the role as a parent. The distractors indicate the professor has not cared for the sick child in an effective way. Taking the child to a daycare center exposes other children to a potential infection. Taking the child to one's office does not keep the child comfortable or provide for the child while the professor is teaching.

An experienced nurse says to a new graduate, "When you've practiced as long as I have, you instantly know how to take care of psychotic patients." What information should the new graduate consider when analyzing this comment? Select all that apply. a. The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. b. New research findings should be integrated continuously into a nurse's practice to provide the most effective care. c. Experience provides mental health nurses with the essential tools and skills needed for effective professional practice. d. Experienced psychiatric nurses have learned the best ways to care for mentally ill patients through trial and error. e. An intuitive sense of patients' needs guides effective psychiatric nurses.

ANS: A, B Evidence-based practice involves using research findings and standards of care to provide the most effective nursing care. Evidence is continuously emerging, so nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care.

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a. Focus dialogues with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient to identify strengths, limitations, and problems.

ANS: A, B The correct actions are part of the termination phase. The other actions would be used in the working and orientation phases.

An experienced nurse says to a new graduate, "When you've practiced as long as I have, you will instantly know how to take care of psychotic patients." What is the new graduate's best analysis of this comment? (Select all that apply.) a. The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. b. New research findings must be continually integrated into a nurse's practice to provide the most effective care. c. Experience provides mental health nurses with the tools and skills needed for effective professional practice. d. Experienced psychiatric nurses have learned the best ways to care for psychotic patients through trial and error. e. Effective psychiatric nurses should be continually guided by an intuitive sense of patients' needs.

ANS: A, B Evidence-based practice involves using research findings to provide the most effective nursing care. Evidence is continually emerging; therefore, nurses cannot rely solely on experience. The effective nurse also maintains respect for each patient as an individual. Overgeneralization compromises that perspective. Intuition and trial and error are unsystematic approaches to care.

Which benefits are most associated with use of telehealth technologies? Select all that apply. a. Cost savings for patients b. Maximize care management c. Access to services for patients in rural areas d. Prompt reimbursement by third party payers e. Rapid development of trusting relationships with patients

ANS: A, B, C Telehealth has shown it can maximize health and improve disease management skills and confidence with the disease process. Many rural parents have felt disconnected from services; telehealth technologies can solve those problems. Although telehealth's improved health outcomes regularly show cost savings for payers, one significant barrier is the current lack of reimbursement for remote patient monitoring by third party payers. Telehealth technologies have not shown rapid development of trusting relationships.

2. A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.

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.

2. A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

ANS: A, B, D Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.) A. "I am easily manipulated and need to work on this prior to caring for these clients." B. "Because of my father's alcoholism, I need to examine my attitude toward these clients." C. "I need to review the side effects of the medications used in the withdrawal process." D. "I'll need to set boundaries to maintain a therapeutic relationship." E. "I need to take charge when dealing with clients diagnosed with substance disorders."

ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse's ability to establish therapeutic relationships with these clients.

1. A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) "My nurse: a. talks in language I can understand' b. helps me keep track of my medications." c. is willing to go to social activities with me." d. lets me do whatever I choose without interfering." e. looks at me as a whole person with different needs."

ANS: A, B, E Each correct answer demonstrates caring is an example of appropriate nursing foci: communicating at a level understandable to the patient, using holistic principles to guide care, and providing medication supervision. The incorrect options suggest a laissez-faire attitude on the part of the nurse, when the nurse should instead provide thoughtful feedback and help patients test alternative solutions or violate boundaries.

3. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injury

ANS: A, B, E Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury.

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.) A. "A diet rich in protein will promote hepatic healing." B. "This condition leads to a rise in serum ammonia resulting in impaired mental functioning." C. "In this condition, blood accumulates in the abdominal cavity." D. "Neomycin and lactulose are used in the treatment of this condition." E. "This condition is caused by the inability of the liver to convert ammonia to urea."

ANS: A, C The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing and that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

A nurse is interacting with patients in a psychiatric unit. Which statements reflect use of therapeutic communication? Select all that apply. a. "Tell me more about that situation." b. "Let's talk about something else." c. "I notice you are pacing a lot." d. "I'll stay with you a while." e. "Why did you do that?"

ANS: A, C, D The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate changing the subject and probing, which are non-therapeutic techniques.

5. Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics are the primary focuses of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

ANS: A, C, D The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective.

14. A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? Select all that apply. A. "Can you tell me your name and where you live?" B. "Have you ever traveled suddenly or unexpectedly away from home?" C. "Have you recently experienced any traumatic event?" D. "Have you ever felt detached from your environment?" E. "Have you had any history of memory problems?"

ANS: A, C, E An individual who has generalized amnesia has amnesia for his or her identity and total life history. The first question assesses orientation to identity. Items C and D assess for awareness of current issues and historical issues, respectively. Affirmative descriptions of either of these issues would rule out generalized amnesia.

13. A client is diagnosed with illness anxiety disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply. A. Obsessive-compulsive traits B. Pseudocyesis C. Disabling fear of having a serious illness D. Multiple pronounced physical symptoms E. Depression

ANS: A, C, E Illness anxiety disorder involves a preoccupation with and fear of having or acquiring a serious disease. Somatic symptoms are either absent or mild in intensity.

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.

15. Which of the following somatic symptom and dissociative disorders are identified with known effective pharmacological treatments for that disorder? Select all that apply. A. Antidepressants have been used effectively in treating pain associated with somatic symptom disorder. B. Lithium has been effective in treating illness anxiety disorder. C. Muscle relaxants have been effective in resolving conversion disorder symptoms. D. The antidepressant clomipramine (Anafranil) has shown promise in treating depersonalization-derealization disorder.

ANS: A, D The nurse should recognize that psychological therapies are central treatment modalities for these disorders, although evidence exists that for specific issues (as those identified in items A and C), psychopharmacological agents have demonstrated effectiveness.

4. Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

ANS: A, D, E Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.

Which findings are signs of a person who is mentally healthy? Select all that apply. a. Says, "I have some weaknesses, but I feel I'm important to my family and friends." b. Adheres strictly to religious beliefs of parents and family of origin. c. Spends all holidays alone watching old movies on television. d. Considers past experiences when deciding about the future. e. Experiences feelings of conflict related to changing jobs.

ANS: A, D, E Mental health is a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem.

1. A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

ANS: A, E Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiological well-being. The other topics are also important but are not priority topics.

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply. a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy. The nurse should try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties. d. The nurse should begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma." e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

ANS: A, E The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse's relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

Alicia, a 31 year old patient, is flirting with a peer. She is overheard asking him to convince staff to give her privileges to leave the inpatient mental health unit. Later she offers you a back rub in exchange receiving her 10:00 pm Xanax an hour early. Which responses to such behaviors would be themes therapeutic? Select all that apply. a. label the behavior as undesirable, and explore with alicia more effective ways to meet her needs. b. by role playing, demo other approaches alicia could use to meet her needs c. advise the other patients that alicia is being manipulative and that they should ignore her when she behaves this way d. bargain with alicia to determine a reasonable compromise regarding how much of such behavior is acceptable before she crosses the line e. explain that such behavior is unacceptable, and give alicia specific examples of consequences that will be enacted if the behavior continues f. ignore the behavior for the time being so alicia will find it unrewarding and in turn seek other, and hopefully more adaptive, ways to meet her needs

ANS: A,B,E

Belinda is a 24-year-old patient with borderline personality disorder (BPD). She is admitted to the inpatient psychiatric unit following a suicide attempt. You are caring for Belinda. Which of the following statements by Belinda illustrates a primary coping style of persons with BPD? a. "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" b. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." c. "I will never again speak to any of my messed up family members. I know that this will help me be more functional." d. "I promise I am not feeling suicidal. I won't hurt myself."

ANS: B

Josie, a 27 year old patient complains that the most of the staff do not like her or care what happens to her, but you are special and she can tell you that you are a caring person. She talks with you about being unsure of what she want to do with her life and her "mix-up feelings" about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it "makes the numbness stops." Given the presentation, which personality disorder would you suspect? a. obsessive compulsive b. borderline c. antisocial d. schizotypal

ANS: B

Which statement about persons with personality disorders is accurate? a. they, unlike those with mood or psychotic disorders, are at very low risk of suicide b. they tend not to perceive themselves as having a problem but instead believe their problems are caused by how others behave toward them c. they are believed to be purely psychological disorders, that is, disorders arising from psychological rather than neurological or other other physiological abnormalities d. their symptoms are not as disabling as most other mental disorders, therefore their care tends to be less challenging and complicated for staff

ANS: B

Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: a. document the other worker's assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the worker's impression by contacting the patient's significant other. d. discuss the worker's impression with the patient during the assessment interview.

ANS: B Assessment should include data obtained from both the primary and reliable secondary sources. The nurse, bearing in mind the possible effects of counter-transference, should evaluate biased assessments by others as objectively as possible.

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

ANS: B Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

1. Which scenario best demonstrates an example of eustress? An individual: a. loses a beloved family pet. b. prepares to take a 1 week vacation to a tropical island with a group of close friends. c. receives a bank notice there were insufficient funds in their account for a recent rent payment. d. receives notification that their current employer is experiencing financial problems and some workers will be terminated.

ANS: B Eustress is beneficial stress; it motivates people to develop skills they need to solve problems and meet personal goals. Positive life experiences produce eustress. Going on a tropical vacation is an exciting, relaxing experience and an example of eustress. Losing the family pet, worrying about employment security, and having financial problems are examples of distress, a negative experience that drains energy and can lead to significant emotional problems.

A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic? a. "Let's talk about something other than the CIA." b. "It sounds like you're concerned about your privacy." c. "The CIA is prohibited from operating in health care facilities." d. "You have lost touch with reality, which is a symptom of your illness."

ANS: B It is important not to challenge the patient's beliefs, even if they are unrealistic. Challenging undermines the patient's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patient's message conveys. The correct response uses the therapeutic technique of reflection. The other comments are non-therapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the patient has lost touch with reality is truthful, but uncompassionate.

The patient says, "My marriage is just great. My spouse and I always agree." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patient's communication is: a. clear. b. mixed. c. precise. d. inadequate.

ANS: B Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The patient's verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.

A new staff nurse completes an orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans.

ANS: B Prescriptive privileges are granted to master's-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. Note that this question was also offered for Chapter 1.

Which entry in the medical record best meets the requirement for problem-oriented charting? a. "A: Pacing and muttering to self. P: Sensory perceptual alteration related to internal auditory stimulation. I: Given fluphenazine HCL (Prolixin) 2.5 mg po at 0900 and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg po. I: Haloperidol (Haldol) 2 mg po given at 0900. E: Returned to lounge at 0930 and quietly watched TV." c. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg po and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." d. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg po administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

ANS: B Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.

"QSEN" refers to: a. Qualitative Standardized Excellence in Nursing b. Quality and Safety Education for Nurses c. Quantitative Effectiveness in Nursing d. Quick Standards Essential for Nurses

ANS: B QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.

19. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

9. A soldier returns to the united states from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my family and friends." b. "I saw my best friend get killed by a roadside bomb. It should have been me instead." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education but I'm not sure how I will fit in with other college students."

ANS: B The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distractor indicates flashbacks, which is common with individuals with PTSD but is not solely indicative of further problems. The other distractors are normal emotions associated with returning home and change.

35. A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

ANS: B The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

3. A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

ANS: B The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.

A nurse wants to assess an adult patient's recent memory. Which question would best yield the desired information? a. "Where did you go to elementary school?" b. "What did you have for breakfast this morning?" c. "Can you name the current president of the United States?" d. "A few minutes ago, I told you my name. Can you remember it?"

ANS: B The patient's recall of a meal provides evidence of recent memory. Two incorrect responses are useful to assess immediate and remote memory. The other distracter assesses the patient's fund of knowledge.

Two nursing students discuss career plans after graduation. One student wants to enter psychiatric nursing. The other student asks, "Why would you want to be a psychiatric nurse? All they do is talk. You will lose your skills." Select the best response by the student interested in psychiatric nursing. a. "Psychiatric nurses practice in safer environments than other specialties and nurse-to-patient ratios are better because of the nature of patients' problems." b. "Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I'm challenged by those situations." c. "I think I will be good in the mental health field. I do not like clinical rotations in school, so I do not want to continue them after I graduate." d. "Psychiatric nurses do not have to deal with as much pain and suffering as medical surgical nurses. That appeals to me."

ANS: B The practice of psychiatric nursing requires a different set of skills than medical surgical nursing, although substantial overlap does exist. Psychiatric nurses must be able to help patients with medical and mental health problems, reflecting the holistic perspective these nurses must have. Nurse-patient ratios and workloads in psychiatric settings have increased, similar to other specialties. Psychiatric nursing involves clinical practice, not simply documentation. Psychosocial pain is real and can cause as much suffering as physical pain.

24. A staff nurse tells another nurse, "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."

ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.

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 nurse introduces the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.

ANS: B A contract emphasizes that the nurse works with the patient rather than doing something for the patient. "Working with" is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden.

12. Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of spousal abuse. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

ANS: B A history of prior aggression or violence is the best predictor of patients who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

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.

7. An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male nursing assistant and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."

ANS: B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort.

A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes compliance with treatment. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

When you are educating Erin and her mother about the medication dosage and adverse effects, Erin becomes upset and tearful, stating, "No! I will not take that medication!" Which of the following is the most likely reason for Erin's feelings? A) Erin feels embarrassed to be taking psychiatric medication. B) Erin is upset about the possible adverse effect of weight gain. C) Erin is worried about the common adverse effect of sexual problems. D) Erin's resistance is typical of her characteristics of rigidity and needing control.

ANS: B Atypical antipsychotic agents may be helpful in improving mood and decreasing obsessional behaviours and resistance to weight gain but are not well accepted by patients who are frightened by the adverse effect of weight gain. There is nothing in the scenario to suggest Erin is embarrassed. Sexual adverse effects are more common with SRRI medication than atypical antipsychotics. Erin may have the characteristics described in option d, which are typical of patients with anorexia; however, during medication education it is more likely for her to be upset over the possibility of an adverse effect.

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.

9. Which of the following statements accurately describes dissociative fugue? A. Dissociative fugue is not precipitated by stressful events. B. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of one's past. C. Dissociative amnesia and dissociative fugue are completely different types of disorders. D. Dissociative fugue is characterized by a sense of observing oneself from outside the body.

ANS: B Dissociative fugue is characterized by unexpected travel or bewildered wandering, and amnesia for all or part of one's past. Dissociative fugue is a subtype of dissociative amnesia.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

17. A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety.

ANS: B Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice.

In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

ANS: B If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention? a. Conduct mental health assessments. b. Prescribe psychotropic medication. c. Establish therapeutic relationships. d. Individualize nursing care plans.

ANS: B In most states, prescriptive privileges are granted to master's-prepared nurse practitioners who have taken special courses on prescribing medication. The nurse prepared at the basic level is permitted to perform mental health assessments, establish relationships, and provide individualized care planning.

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.

12. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change suicide attempts b. Maintaining consistent limits c. Monitoring d. Using aversive therapy

ANS: B Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques. See relationship to audience response question. REF: Page 463 (Table 24-2) | Page 469 (Table 24-4) | Page 473-474

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI)

ANS: B Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive. REF: Page 468-469

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.

An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient which of the following? a. To eat a small meal after purging b. Not to skip meals or restrict food c. To increase oral intake after 4 p.m. daily. d. The value of reading journal entries aloud to others

ANS: B One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 p.m. will lead to late-day bingeing. Journal entries are private.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

16. A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

ANS: B Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness? The patient: a. reports occasional sleeplessness and anxiety. b. reports a consistently sad, discouraged, and hopeless mood. c. is able to describe the difference between "as if" and "for real." d. perceives difficulty making a decision about whether to change jobs.

ANS: B The correct response describes a mood alteration, which reflects mental illness. The distracters describe behaviors that are mentally healthy or within the usual scope of human experience.

10. An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."

ANS: B The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

ANS: B The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD. See relationship to audience response question. REF: Page 463 (Table 24 - 2) | Page 471-472

As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurse's action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patient's diversional activity deficit. d. The nurse's action assists the patient's integration into community living.

ANS: B The invitation creates a social relationship rather than a therapeutic relationship.

Which component of treatment of mental illness is specifically recognized by Quality and Safety Education for Nurses (QSEN)? a. All genomes are unique. b. Care is centered on the patient. c. Healthy development is vital to mental health. d. Recovery occurs on a continuum from illness to health.

ANS: B The key areas of care promoted by QSEN are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

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.

7. An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: B The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

30. A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain, but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

ANS: B The patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurse's understanding of the patient's distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the patient. REF: Page 467-468

13. A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

ANS: B The patient's threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

When a nursing student expresses concerns about how mental health nurses "lose all their nursing skills," the best response by the mental health nurse is: a. "Psychiatric nurses practice in safer environments than other specialties. Nurse-to-patient ratios must be better because of the nature of the patients' problems." b. "Psychiatric nurses use complex communication skills as well as critical thinking to solve multidimensional problems. I am challenged by those situations." c. "That's a misconception. Psychiatric nurses frequently use high technology monitoring equipment and manage complex intravenous therapies." d. "Psychiatric nurses do not have to deal with as much pain and suffering as medical-surgical nurses do. That appeals to me."

ANS: B The practice of psychiatric nursing requires a different set of skills than medical-surgical nursing, though there is substantial overlap. Psychiatric nurses must be able to help patients with medical as well as mental health problems, reflecting the holistic perspective these nurses must have. Nurse-patient ratios and workloads in psychiatric settings have increased, just like other specialties. Psychiatric nursing involves clinical practice, not just documentation. Psychosocial pain and suffering are as real as physical pain and suffering.

Two years ago, a patient was diagnosed with bulimia nervosa, and she has weighed 90 kg for the past 12 months. The patient is generally happy with her life and indicates that she has no resistance to weight gain. Which is the best medication to help control the obsessive-compulsive behaviour, now that the patient has reached a maintenance weight? a. Olanzapine (Zyprexa) b. Fluoxetine (Prozac) c. Chlorpromazine (Thorazine) d. Fat soluble vitamins

ANS: B The selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) has been found clinically useful in reducing obsessive-compulsive behaviour after the patient has reached a maintenance weight. Conventional antipsychotics such as chlorpromazine (Thorazine) may be helpful for delusional or overactive patients (Halmi, 2008). Atypical antipsychotic agents such as olanzapine (Zyprexa) are helpful in improving mood and decreasing obsessional behaviours and resistance to weight gain; although this may be a choice, it is not the best choice because the patient is not experiencing mood problems or resistance to weight gain.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

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.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

ANS: B Without exception, individuals with personality disorders have problems with social interaction with others, hence, the diagnosis of "impaired social interaction." For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to patients with personality disorders; each might apply to selected clinical diagnoses, but not to others. REF: Page 458 | Page 467 (Table 24-3)

A patient shows the nurse an article from the Internet about a health problem. Which characteristic of the web site's address most alerts the nurse that the site may have biased and prejudiced information? a. Address ends in ".org" b. Address ends in ".com" c. Address ends in ".gov" d. Address ends in ".net"

ANS: B Financial influences on a site are a clue that the information may be biased. ".com" at the end of the address indicates that the site is a commercial one. ".gov" indicates that the site is maintained by a government entity. ".org" indicates that the site is nonproprietary; the site may or may not have reliable information, but it does not profit from its activities. ".net" can have multiple meanings.

Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community and diagnosed with serious and persistent mental illness? Within 3 months, the patient will: a. deny suicidal ideation. b. report a sense of well-being. c. take medications as prescribed. d. attend clinic appointments on time

ANS: B Recovery emphasizes managing symptoms, reducing psychosocial disability, and improving role performance. The goal of recovery is to empower the individual with mental illness to achieve a sense of meaning and satisfaction in life and to function at the highest possible level of wellness. The incorrect options focus on the classic medical model rather than recovery.

Which research evidence would most influence a group of nurses to change their practice? a. Expert committee report of recommendations for practice b. Systematic review of randomized controlled trials c. Non-experimental descriptive study d. Critical pathway

ANS: B Research findings are graded using a hierarchy of evidence. A systematic review of randomized controlled trials is level A and provides the strongest evidence for changing practice. Expert committee recommendations and descriptive studies lend less powerful and influential evidence. A critical pathway is not evidence; it incorporates research findings after they have been analyzed.

1. A patient cries as the nurse explores the patient's feelings about the death of a close friend. The patient sobs, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse facilitate communication?Select all that apply. a. "Why do you think you are so upset?" b. "I can see that you feel sad about this situation." c. "The loss of a close friend is very painful for you." d. "Crying is a way of expressing the hurt you are experiencing." e. "Let's talk about something else because this subject is upsetting you."

ANS: B, C, D Reflecting ("I can see that you feel sad," "This is very painful for you") and giving information ("Crying is a way of expressing hurt") are therapeutic techniques. "Why" questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

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 patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. d. Tell the patient, "Your ideas are not realistic." e. Reassure the patient, "You are safe here."

ANS: B, C, E During the assessment interview, the nurse should listen attentively and accept the patient's statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine development of trust between the nurse and patient.

A patient in the emergency department says, "Voices say someone is stalking me. They want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat." Which aspects of the patient's mental health have the greatest and most immediate concern to the nurse? Select all that apply. a. Happiness b. Appraisal of reality c. Control over behavior d. Effectiveness in work e. Healthy self-concept

ANS: B, C, E The aspects of mental health of greatest concern are the patient's appraisal of and control over behavior. The appraisal of reality is inaccurate. There are auditory hallucinations, delusions of persecution, and delusions of grandeur. In addition, the patient's control over behavior is tenuous, as evidenced by the plan to stab anyone who seems threatening. A healthy self-concept is lacking, as evidenced by the delusion of grandeur. Data are not present to suggest that the other aspects of mental health (happiness and effectiveness in work) are of immediate concern.

1. A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply. a. The patient was uncooperative b. The patient's subjective responses c. Only data obtained from the patient's verbal responses d. A description of the patient's behavior during the interview e. Analysis of why the patient was unresponsive during the interview

ANS: B, D Both content and process of the interview should be documented. Providing only the patient's verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient's behavior would be speculation, which is inappropriate.

MULTIPLE RESPONSE 1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists. REF: Page 463 (Table 24 - 2) | Page 465-466

A novice nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors will be helpful in meeting the nurse's goal? Select all that apply. a. Sitting behind a desk, facing the patient b. Introducing self to a patient and identifying own role c. Maintaining control of discussions by asking direct questions d. Using facial expressions to convey interest and encouragement e. Assuming an open body posture and sometimes mirror imaging

ANS: B, D, E Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse's verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort.

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate? a. "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." b. "Yes, your parents may find out what you say, but it is important that they know about your problems." c. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." d. "It sounds as though you are not really ready to work on your problems and make changes."

ANS: C Adolescents are very concerned with confidentiality. The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The incorrect responses are not true, will not inspire the confidence of the patient, or are confrontational.

A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response. a. "Don't talk that way. Of course you will leave here!" b. keep up the good work, and you certainly will." c. "You don't think you're making progress?" d. "Everyone feels that way sometimes."

ANS: C By asking if the patient does not believe that progress has been made, the nurse is reflecting by putting into words what the patient is hinting. By making communication more explicit, issues are easier to identify and resolve. The remaining options are non-therapeutic techniques. Telling the patient not to "talk that way" is disapproving. Saying that everyone feels that way at times minimizes feelings. Telling the patient that good work will always result in success is falsely reassuring.

29. A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

ANS: C Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.

A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item, "Encourage patient to attend one psychoeducational group daily"? a. Assessment b. Analysis c. Implementation d. Evaluation

ANS: C Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

Select the most appropriate label to complete this nursing diagnosis: ___________ related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Social isolation d. Powerlessness

ANS: C Nursing diagnoses are selected based on the etiological factors and assessment findings, or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

ANS: C Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern.

16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. A nurse is responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps patients know that what they said was understood.

ANS: C Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. A nurse breaking silences is not a principle related to silences. It is inaccurate to say that patients withdraw during long silences or that silence helps patients know that they are understood. Feedback helps patients know they have been understood.

15. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.

3. A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system? a. Thalamus b. Parietal lobe c. Hypothalamus d. Pituitary gland

ANS: C The individual will find this experience stressful. The hypothalamus functions as the command-and-control center when receiving stressful signals. The hypothalamus responds to signals of stress by engaging the autonomic nervous system. The parietal lobe is responsible for the interpretation of other sensations. The thalamus processes messages associated with pain and wakefulness. The pituitary gland may be involved in other aspects of the person's response but would not stimulate the autonomic nervous system.

Which behavior shows that a nurse values autonomy? The nurse: a. suggests one-on-one supervision for a patient who has suicidal thoughts. b. informs a patient that the spouse will not be in during visiting hours. c. discusses options and helps the patient weigh the consequences. d. sets limits on a patient's romantic overtures toward the nurse.

ANS: C A high level of valuing is acting on one's belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors.

10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patient's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately. REF: Page 468 (Box 24 - 2) | Page 473-474

Which female patient should the nurse recognize as having the highest risk to have or develop bulimia nervosa? The one who: a) grew up in an underserved area b) lives in a society influenced by Eastern cultural beliefs c) is 20 years old d) Is Asian Canadian

ANS: C A) The degree of public services has not been linked as a predisposing factor for bulimia nervosa. B) Women living in industrialized nations influenced by Western culture are more predisposed to eating disorders than those influenced more strongly by Eastern cultural beliefs. C) Bulimia nervosa is rarely seen in children younger than 12 years, whereas anorexia nervosa may start as early as between the ages of 7 and 12. D) There has not been much research that has focused on eating disorders and ethnicity; however, there is some evidence that Canadian Jewish women and Aboriginal women are at greater risk for developing an eating disorder than their non-Jewish and non-Aboriginal counterparts.

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? a. "Accepting gifts violates the policies and procedures of the facility." b. "I'm glad you feel so much better now. Thank you for the beautiful necklace." c. "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." d. "Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."

ANS: C Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient's gesture of appreciation, but the gift should not be accepted.

When a new bill introduced in Congress reduces funding for care of persons with mental illness, a group of nurses writes letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled? a. Recovery b. Attending c. Advocacy d. Evidence-based practice

ANS: C An advocate defends or asserts another's cause, particularly when the other person lacks the ability to do that for self. Examples of individual advocacy include helping patients understand their rights or make decisions. On a community scale, advocacy includes political activity, public speaking, and publication in the interest of improving the human condition. Since funding is necessary to deliver quality programming for persons with mental illness, the letter- writing campaign advocates for that cause on behalf of patients who are unable to articulate their own needs.

Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counselling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? A) "I purge only once a day now instead of twice." B) "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." C) "I am a hard worker and I am very compassionate toward others." D) "I always purge when I'm alone so that I'm not a bad role model for my younger sister."

ANS: C An appropriate overall goal for the bulimic patient would include that the patient be able to identify personal strengths, leading to improved self-esteem. Purging only once a day instead of two is incorrect because the goal is to refrain from purging altogether. A goal is for the patient to express feelings without food references. Purging when alone is incorrect because the patient is still purging.

Which comment best indicates that a patient perceived the nurse was caring? "My nurse: a. always asks me which type of juice I want to help me swallow my medication." b. explained my treatment plan to me and asked for my ideas about how to make it better." c. spends time listening to me talk about my problems. That helps me feel like I am not alone." d. told me that if I take all the medicines the doctor prescribes, then I will get discharged sooner."

ANS: C Caring evidences empathetic understanding as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The distracters give examples of statements that demonstrate advocacy or giving advice.

4. A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care worker's behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

ANS: C Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for which primary purpose? a. Maintaining patients' concentration and attention b. Shifting the patients' focus from food to psychotherapy c. Promoting processing of anxiety associated with eating d. Focusing on weight control mechanisms and food preparation

ANS: C Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. See relationship to audience response question. REF: Page 473-474

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to which of the following? a. Self-monitoring of daily food and fluid intake b. Establishing the desired daily weight gain c. How to recognize hypokalemia d. Self-esteem maintenance

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

17. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.

A category 5 tornado occurred in a community of 400 people resulting in destruction of many homes and businesses. In the 2 years after this disaster, 140 individuals were diagnosed with posttraumatic stress disorder (PTSD). Which term best applies to these newly diagnosed cases? a. Prevalence b. Co-morbidity c. Incidence d. Parity

ANS: C Incidence refers to the number of new cases of mental disorders in a healthy population within a given period of time. Prevalence describes the total number of cases, new and existing, in a given population during a specific period of time, regardless of when they became ill. Parity refers to equivalence, and legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage. Co-morbidity refers to having more than one mental disorder at a time.

1. A client diagnosed with somatic symptom disorder is most likely to exhibit which personality disorder characteristics? A. Uses "splitting" and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange

ANS: C It has been suggested that in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These features include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself. Somatic symptom disorder is characterized by the expression of multiple somatic complaints associated with psychosocial distress and without medical basis.

4. Carly has been diagnosed with somatic symptom disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? A. The family agrees that Carly began having physical symptoms after she lost her job. B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. C. Carly's mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. D. Carly states she noticed feeling hotter than usual the last time she had a headache.

ANS: C It is important for the nurse to identify gains that the symptoms might be providing for the client, since these can reinforce illness behavior. Having family attend to the patient when she is symptomatic could reinforce increased dependency and attention needs.

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters. REF: Page 468 (Box 24-2) | Page 469 (Table 24-4)

The spouse of a patient diagnosed with schizophrenia says, "I don't understand how events from childhood have anything to do with this disabling illness." Which response by the nurse will best help the spouse understand the cause of this disorder? a. "Psychological stress is the basis of most mental disorders." b. "This illness results from developmental factors rather than stress." c. "Research shows that this condition more likely has a biological basis." d. "It must be frustrating for you that your spouse is sick so much of the time."

ANS: C Many of the most prevalent and disabling mental disorders have strong biological influences. Genetics are only one part of biological factors. Empathy does not address increasing the spouse's level of knowledge about the cause of the disorder. The other distracters are not established facts.

19. Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

ANS: C Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or for those who are borderline bipolar.

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 42 kg, a loss of 14 kg. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

ANS: C Overly controlled eating behaviours, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese. See relationship to audience response question.

5. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt-producing.

ANS: C Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evident in the comments. REF: Page 459-460 | Page 469 (Table 24 - 4)

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

22. A patient with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.

Which issues should a nurse address during the first interview with a patient with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources

ANS: C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking. REF: Page 470-471 | Page 473-474 (Case Study and Nursing Care Plan 24-1)

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.

3. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.

According to current theory, which of the following is true of eating disorders? A) They are psychotic disorders in which patients experience body dysmorphic disorder. B) They are frequently misdiagnosed. C) They are possibly influenced by sociocultural factors. D) They are rarely co-morbid with other mental health disorders.

ANS: C The Western cultural ideal that equates feminine beauty with tall, thin models has received much attention in the media as a cause of eating disorders. Studies have shown that culture influences the development of self-concept and satisfaction with body size. Eating disorders are not psychotic disorders. There is no evidence that eating disorders are frequently misdiagnosed. Comorbidity for patients with eating disorders is more likely than not. Personality disorders, affective disorders, and anxiety frequently occur with eating disorders.

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? 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?"

ANS: 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.

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients." Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. Wish for revenge d. Preoccupation with the incident

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distracters are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic. See relationship to audience response question. REF: Page 463 (Table 24 - 2) | Page 466-467 | Page 469 (Table 24 - 4)

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

ANS: 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.

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.

During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the patient's ability to weigh alternatives to mutilating behavior. REF: Page 460 | Page 476

27. A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

ANS: C The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations. REF: Page 457-458 | Page 463 (Table 24 - 2)

4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The patient would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control. REF: Page 463 (Table 24-5) | Page 466-467 | Page 469 (Table 24-4)

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

15. A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse should say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Was your husband angry if you did not have dinner ready on time?"

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The other options do not validate patient feelings.

14. A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

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.

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

2. Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? Select all that apply. a. An 8-year-old child watches an R-rated movie with both parents. b. A young adult jumps from a bridge with a bungee cord with a best friend. c. An adolescent is kidnapped and held for 2 years in the home of a sexual predator. d. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. e. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

ANS: C, D, E PTSD usually follows a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture or kidnapping, military combat, sexual assault, and natural disasters such as floods, tornados, earthquakes, and tsunamis; human disasters such as a bus or elevator accident or crime-related events such being taken hostage are additional examples. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumping by adolescents is part of the developmental task and might be frightening but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

Mary Alice is a 37-year-old patient referred to the mental health clinic with a suspected personality disorder. She is withdrawn and suspicious and states she has always preferred to be alone. She describes herself as having "special powers" and states that she is thinking of opening a business where she gives "readings" to people about their future. She states, "I believe we can all read each other's thoughts at times." Based on this presentation, you suspect: a. obsessive-compulsive personality disorder. b. narcissistic personality disorder. c. avoidant personality disorder. d. schizotypal personality disorder (STPD).

ANS: D

17. A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.

24. What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

ANS: D In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

31. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?' d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

Nursing behaviors associated with the implementation phase of nursing process are concerned with: a. participating in mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

ANS: D Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

16. A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Post-traumatic stress disorder often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Post-traumatic stress disorder often strains relationships. I will suggest some community resources for help and support."

ANS: D PSTD precipitates changes that often lead to divorce. Providing support to both the veteran and spouse is important. Confrontation will not be effective. Although providing information is important, ongoing support is more effective.

12. A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)? a. Immediately upon return to the United States from Afghanistan b. Before departing Afghanistan to return to the United States c. One year after returning from Afghanistan d. Screening should be ongoing

ANS: D PTSD can have a long lag time—months to years. Screening should be ongoing.

28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a. the need for psychoeducation. b. medication noncompliance. c. chronic deterioration. d. relapse.

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Examine interventions for possible revision of the target date.

ANS: D Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patient's self-esteem, but after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario? a. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient. c. The patient's poor eye contact is indicative of anger and hostility that were unaddressed. d. The nurse should have assessed the patient's culture before making this diagnosis and plan.

ANS: D The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected. Asian Americans, including persons from the Philippines, often prefer not to engage in direct eye contact.

A nurse documents: "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication

ANS: D The defining characteristics are more related to the nursing diagnosis of impaired verbal communication than to the other nursing diagnoses.

A nurse prepares to assess a new patient who moved to the United States from Central America three years ago. After introductions, what is the nurse's next comment? a. "How did you get to the United States?" b. "Would you like for a family member to help you talk with me?" c. "An interpreter is available. Would you like for me to make a request for these services?" d. "Are you comfortable conversing in English, or would you prefer to have a translator present?"

ANS: D The nurse should determine whether a translator is needed by first assessing the patient for language barriers. Accuracy of the assessment depends on the ability to communicate in a language that is familiar to the patient. Family members are not always reliable translators. An interpreter may change the patient's responses; a translator is a better resource.

A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? a. Self-esteem-building activities b. Anxiety self-control measures c. Sleep enhancement activitie d. Suicide precautions

ANS: D The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." Patient will: a. show improved use of language. b. demonstrate improved social skills. c. become more independent in decision making. d. select and participate in one group activity per day.

ANS: D The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.

30. A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

ANS: D The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient's laughter) and then elicit the patient's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.

5. A patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are temperature (T), 98.6° F; pulse (P), 72 beats per minute (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected? a. T, 98.6°; P, 64; R, 14 b. T, 98.6°; P, 68; R, 12 c. T, 98.6°; P, 62; R, 16 d. T, 98.6°; P, 84; R, 22

ANS: D The patient would experience stress associated with the anticipation of surgery. In times of stress, the sympathetic nervous system takes over (fight-or-flight response) and sends signals to the adrenal glands, thereby releasing norepinephrine. The circulating norepinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs.

23. A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

A patient says to the nurse, "I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which response should the nurse use to clarify the patient's comment? a. "It sounds as though you were uncomfortable with the content of your dream." b. "I understand what you're saying. Bad dreams leave me feeling tired, too." c. "So you feel as though you did not get enough quality sleep last night?" d. "Can you give me an example of what you mean by 'stoned'?"

ANS: D The technique of clarification is therapeutic and helps the nurse examine the meaning of the patient's statement. Asking for a definition of "stoned" directly asks for clarification. Restating that the patient is uncomfortable with the dream's content is parroting, a non-therapeutic technique. The other responses fail to clarify the meaning of the patient's comment.

22. A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question.

14. Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior.

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. a. Record the patient's answers to questions on the nursing assessment form. b. Ask an advanced practice nurse to perform the assessment interview. c. Call for a mental health advocate to maintain the patient's rights. d. Obtain important information from the family member.

ANS: D When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary. See relationship to audience response question.

An informal group of patients discuss their perceptions of nursing care. Which comment best indicates a patient's perception that his or her nurse is caring? a. "My nurse always asks me which type of juice I want to help me swallow my medication." b. "My nurse explained my treatment plan to me and asked for my ideas about how to make it better." c. "My nurse told me that if I take all the medicines the doctor prescribes I will get discharged soon." d. "My nurse spends time listening to me talk about my problems. That helps me feel like I'm not alone."

ANS: D Caring evidences empathic understanding as well as competency. It helps change pain and suffering into a shared experience, creating a human connection that alleviates feelings of isolation. The incorrect options give examples of statements that demonstrate advocacy or giving advice.

A team of nurses wants to integrate evidence-based practice into a facility's clinical pathways. Which step should the team implement first? a. Acquire findings from published literature. b. Apply the research findings to clinical practice. c. Assess the outcomes of using new research findings. d. Ask questions to identify clinical problems that should be changed.

ANS: D Integrating evidence-based practice is a multistep process rather than a single change event. The first step is to identify clinical problems that should be changed. Each step must proceed in order when integrated into a clinical environment.

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.

Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

Which of the following is a complication of bulimia nervosa? a. Tachycardia b. Hyperchloremia c. Hyperkalemia d. Esophageal tears

ANS: D A complication of bulimia nervosa is esophageal tears caused by self-induced vomiting. Others include bradycardia, hypochloremia, and hypokalemia.

A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

ANS: D A matter-of-fact statement that the nurse's perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviours.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

Your patient, Erin, is a 16-year-old who is newly diagnosed with anorexia. Her psychiatrist is starting her on medication to reduce compulsive behaviours regarding food and resistance to weight gain. You prepare teaching on which class of medication that may help these specific symptoms in eating disorders? A) Mood stabilizers B) Antidepressants Incorrect C) Anxiolytics D) Atypical antipsychotics

ANS: D Atypical antipsychotic agents may be helpful in improving mood and decreasing obsessional behaviours and resistance to weight gain. Mood stabilizers are not specifically used in treatment of eating disorders. The antidepressant fluoxetine (Prozac, an SSRI) has proven useful in reducing obsessive-compulsive behaviour after the patient has reached a maintenance weight. Anxiolytics would be prescribed for anxiety.

Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance

ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

ANS: D Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth. REF: Page 465 | Page 472 (Evidence Based Practice Box)

22. Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland

ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

18. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.

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.

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

ANS: D Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder. (The educator may reformat this question as multiple response.) REF: Page 458-459 | Page 463 (Table 24 - 2)

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, which of the following will the patient do? a. Weigh self accurately using balanced scales b. Limit exercise to less than 2 hours daily c. Select clothing that fits properly d. Gain 1 to 1.5 kg

ANS: D Only the outcome of a gain of 1 to 1.5 kg can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

1. A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I should get the money." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown. REF: Page 469 (Table 24 - 4)

Which individual is demonstrating the highest level of resilience? One who: a. is able to repress stressors. b. becomes depressed after the death of a spouse. c. lives in a shelter for two years after the home is destroyed by fire. d. takes a temporary job to maintain financial stability after loss of a permanent job.

ANS: D Resilience is closely associated with the process of adapting and helps people facing tragedies, loss, trauma, and severe stress. It is the ability and capacity for people to secure the resources they need to support their well-being. Repression and depression are unhealthy. Living in a shelter for two years shows a failure to move forward after a tragedy. See related audience response question.

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

ANS: D Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative. REF: Page 457-458 | Page 463 (Table 24 - 2)

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

24. When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient's affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

ANS: D Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the preaggressive phase but is less effective during escalation.

5. A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

A citizen at a community health fair asks the nurse, "What is the most prevalent mental disorder in the United States?" Select the nurse's best response. a. Schizophrenia b. Bipolar disorder c. Dissociative fugue d. Alzheimer's disease

ANS: D The 12-month prevalence for Alzheimer's disease is 10% for persons older than 65 and 50% for persons older than 85. The prevalence of schizophrenia is 1.1% per year. The prevalence of bipolar disorder is 2.6%. Dissociative fugue is a rare disorder. See related audience response question.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies: a. deviant behaviors. b. present disability or distress. c. people with mental disorders. d. mental disorders people have.

ANS: D The DSM-5 classifies disorders people have rather than people themselves. The terminology of the tool reflects this distinction by referring to individuals with a disorder rather than as a "schizophrenic" or "alcoholic," for example. Deviant behavior is not generally considered a mental disorder. Present disability or distress is only one aspect of the diagnosis.

14. A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

ANS: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

A patient's relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health? a. Effectiveness in work b. Communication skills c. Productive activities d. Fulfilling relationships

ANS: D The information given centers on relationships with others that are described as intense and unstable. The relationships of mentally healthy individuals are stable, satisfying, and socially integrated. Data are not present to describe work effectiveness, communication skills, or activities.

Select the best response for the nurse who receives a question from another health professional seeking to understand the difference between a Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis and a nursing diagnosis. a. "There is no functional difference between the two. Both identify human disorders." b. "The DSM-5 diagnosis disregards culture, whereas the nursing diagnosis takes culture into account. c. The DSM-5 diagnosis describes causes of disorders whereas a nursing diagnosis does not explore etiology." d. "The DSM-5 diagnosis guides medical treatment, whereas the nursing diagnosis offers a framework for identifying interventions for issues a patient is experiencing."

ANS: D The medical diagnosis is concerned with the patient's disease state, causes, and cures, whereas the nursing diagnosis focuses on the patient's response to stress and possible caring interventions. Both tools consider culture. The DSM-5 is multiaxial. Nursing diagnoses also consider potential problems.

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.

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepan (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

8. A client is diagnosed with dissociative identity disorder (DID). What is the primary goal of therapy for this client? A. To recover memories and improve thinking patterns B. To prevent social isolation C. To decrease anxiety and need for secondary gain D. To collaborate among subpersonalities to improve functioning

ANS: D The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among subpersonalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the client's ability to function appropriately and achieve optimal personal potential.

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.

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.

21. Information from a patient's record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. chemical dependence.

ANS: D The nurse should suspect marginal coping skills in a patient with chemical dependence. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.

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 nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will do which of the following? a. Appropriately express angry feelings b. Verbalize two positive things about self c. Verbalize the importance of eating a balanced diet d. Identify two alternative methods of coping with loneliness

ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS: D The patient's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about problems." c. "I don't know how it will help to talk to you about my problems." d. "I want to find a way to deal with my anger without becoming violent."

ANS: D Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during the orientation phase.

18. For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance. REF: Page 468-469 (Box 24 - 2)

A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is correct. d. Differing values are reflected in the two statements.

ANS: D Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

26. A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response? a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."

ANS: D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you." The nurse should: a. invite the interrupting patient to join in the session with the current patient. b. say to the interrupting patient, "I am not available to talk with you at the present time." c. end the unproductive session with the current patient and spend time with the interrupting patient. d. tell the interrupting patient, "This session is 5 more minutes; then I will talk with you."

ANS: D When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse-patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient.

In the shift-change report, an off-going nurse criticizes a patient who wears heavy makeup. Which comment by the nurse who receives the report best demonstrates advocacy? a. "This is a psychiatric hospital, so we expect our patients to behave bizarrely." b. "Let's all show acceptance of this patient by wearing lots of makeup too." c. "Your comments are inconsiderate and inappropriate. Keep the report objective." d. "Our patients need our help to learn behaviors that will help them get along in society."

ANS: D Accepting patients' needs for self-expression and seeking to teach skills that will contribute to their well-being demonstrate respect and are important parts of advocacy. The on-coming nurse needs to take action to ensure that others are not prejudiced against the patient. Humor can be appropriate within the privacy of a shift report but not at the expense of respect for patients. Judging the off-going nurse in a critical way will create conflict. Nurses must show compassion for each other.

A nurse assesses a newly admitted patient diagnosed with major depressive disorder. Which statement is an example of "attending"? a. "We all have stress in life. Being in a psychiatric hospital is not the end of the world." b. "Tell me why you felt you had to be hospitalized to receive treatment for your depression." c. "You will feel better after we get some antidepressant medication started for you." d. "I'd like to sit with you a while so you may feel more comfortable talking with me."

ANS: D Attending is a technique that demonstrates the nurse's commitment to the relationship and reduces feelings of isolation. This technique shows respect for the patient and demonstrates caring. Generalizations, probing, and false reassurances are non-therapeutic.

The nurse records this entry in a patient's progress notes: Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation. How should this documentation be evaluated? a. Uses unapproved abbreviations b. Contains subjective material c. Too brief to be of value d. Excessively wordy e. Meets standards

ANS: E This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.

A nurse prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to an outpatient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best action. a. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary. b. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." c. Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects. d. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."

B

A patient experiencing psychosis asks a psychiatric technician, "What's the matter with me?" The technician replies, "Nothing is wrong with you. You just need to use some self-control." The nurse who overheard the exchange should take action based on: a. the technician's unauthorized disclosure of confidential clinical information. b. violation of the patient's right to be treated with dignity and respect. c. the nurse's obligation to report caregiver negligence. d. the patient's right to social interaction.

B

An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You are right. Federal law requires me to keep clinical information private." b. "I am obligated to share that information with the treatment team." c. "Those kinds of thoughts will make your hospitalization longer." d. "You should share this thought with your psychiatrist."

B

Which action by a nurse constitutes a breach of a patient's right to privacy? a. Documenting the patient's daily behavior during hospitalization b. Releasing information to the patient's employer without consent c. Discussing the patient's history with other staff during care planning d. Asking family to share information about a patient's pre-hospitalization behavior

B

Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

B

A patient with a long history of hypertension and diabetes now develops confusion. The health care provider wants to make a differential diagnosis between Alzheimer's disease and multiple infarcts. Which diagnostic procedure should the nurse expect to prepare the patient for first a. Skull x-rays b. Computed tomography (CT) scan c. Positron-emission tomography (PET) d. Single-photon emission computed tomography (SPECT)

B A CT scan shows the presence or absence of structural changes, including cortical atrophy, ventricular enlargement, and areas of infarct, information that would be helpful to the health care provider. PET and SPECT show brain activity rather than structure and may occur later. See relationship to audience response question.

By which mechanism do selective serotonin reuptake inhibitors (SSRI) improve depression? a. Destroying increased amounts of serotonin b. Making more serotonin available at the synaptic gap c. Increasing production of acetylcholine and dopamine d. Blocking muscarinic and 1 norepinephrine receptors

B Depression is thought to be related to lowered availability of the neurotransmitter serotonin. SSRIs act by blocking reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. SSRIs prevent destruction of serotonin. SSRIs have little or no effect on acetylcholine and dopamine production. SSRIs do not produce muscarinic or 1 norepinephrine blockade.

The therapeutic action of neurotransmitter inhibitors that block reuptake cause: a. decreased concentration of the blocked neurotransmitter in the central nervous system. b. increased concentration of the blocked neurotransmitter in the synaptic gap. c. destruction of receptor sites specific to the blocked neurotransmitter. d. limbic system stimulation.

B If the reuptake of a substance is inhibited, it accumulates in the synaptic gap, and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

A nurse would anticipate that treatment for a patient with memory difficulties might include medications designed to: a. inhibit gamma-aminobutyric acid (GABA) b. prevent destruction of acetylcholine c. reduce serotonin metabolism d. increase dopamine activity

B Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA affects anxiety rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson's disease rather than improving memory.

The nurse prepares to assess a patient diagnosed with major depression for disturbances in circadian rhythms. Which question should the nurse ask this patient? a. "Have you ever seen or heard things that others do not?" b. "What are your worst and best times of the day?" c. "How would you describe your thinking?" d. "Do you think your memory is failing?"

B Mood changes throughout the day may be related to circadian rhythm disturbances. Questions about sleep pattern are also relevant to circadian rhythms. The distracters apply to assessment for illusions and hallucinations, thought processes, and memory.

A patient has fear as well as increased heart rate and blood pressure. The nurse suspects increased activity of which neurotransmitter? a. Gamma-aminobutyric acid (GABA) b. Norepinephrine c. Acetylcholine d. Histamine

B Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight." GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

A drug blocks the attachment of norepinephrine to 1 receptors. The patient may experience: a. hypertensive crisis b. orthostatic hypotension c. severe appetite disturbance. d. an increase in psychotic symptoms

B Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of 1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Teach patients ways of minimizing this phenomenon.

A professional football player is seen in the emergency department after losing consciousness from an illegal block. Prior to discharge, the nurse assists the patient to schedule an outpatient computed tomography (CT) scan for the next day. Which strategy should the nurse use to ensure the patient remembers the appointment? a. Write the appointment day, time, and location on a piece of paper and give it to the player. b. Log the appointment day, time, and location into the player's cell phone calendar feature. c. Ask the health care provider to admit the patient to the hospital overnight. d. Verbally inform the patient of the appointment day, time, and location.

B This player may have suffered repeated head injuries with damage to the hippocampus. The hippocampus has significant role in maintaining memory. Logging the appointment into the player's cell phone calendar will remind him of the appointment the next day. Paper will be lost, and the patient is unlikely to remember verbal instruction. Hospitalization is unnecessary. See relationship to audience response question. Caution: This question requires students to apply previous learning regarding central nervous system anatomy and physiology.

A patient diagnosed with bipolar disorder has an unstable mood, aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group? a. Psychostimulants b. Mood stabilizers c. Anticholinergics d. Antidepressants

B The symptoms describe mania, which is effectively treated by mood stabilizers, such as lithium, and selected anticonvulsants (carbamazepine, valproic acid, and lamotrigine). Drugs from the other classifications listed are not effective in the treatment of mania.

A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now." Select the nurse's best response. a. "I will get the forms for you right now and bring them to your room." b. "Since you signed your consent for treatment, you may leave if you desire." c. "I will get them for you, but let's talk about your decision to leave treatment." d. "I cannot give you those forms without your health care provider's permission."

C

After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the nurse on duty and says, "Please document administration of the medication for me. My password is alpha1." The nurse receiving the call should: a. fulfill the request promptly. b. document the caller's password. c. refer the matter to the charge nurse to resolve. d. report the request to the patient's health care provider.

C

The intervention that will be most effective in preventing a nurse from making decisions that will lead to legal difficulties is a. asking a peer to review nursing intervention related decisions. b. balancing the rights of the client and the rights of society. c. maintaining currency in state laws affecting nursing practice. d. seeking value clarification about fundamental ethical principles.

C

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. cardiac dysrhythmia b. hypotensive shock c. hypertensive crisis d. hypoglycemia

C Patients taking MAO-inhibiting drugs must be on a low tyramine diet to prevent hypertensive crisis. In the presence of MAO inhibitors, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A patient is hospitalized for severe depression. Of the medications listed below, the nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium) b. clozapine (Clozaril) c. sertraline (Zoloft) d. tacrine (Cognex)

C Sertraline (Zoloft) is an SSRI. This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimer's disease.

37. Paula is attending an education class on addictive disorders. She suspects that her husband may be abusing opiates since he has been taking pills given to him by his brother and she knows the brother had been taking oxycodone for back pain. She asks the nurse how to interpret her husband's behaviors. Which of the following observations by Paula are consistent with opioid intoxication? Select all that apply. 1) "Sometimes he seems euphoric and other times he acts like he doesn't care about anything." 2) "Last night he went out without a coat on and it was 15 degrees outside." 3) "While we were talking at dinner his speech was rapid and he seemed hyperalert to everything in the environment." 4) "He's been having trouble remembering things." 5) "Sometimes it looks like his pupils are very small."

Correct 1: One manifestation of opioid intoxication is an initial period of euphoria followed by apathy, which is indicated by her statement that "sometimes he acts like he doesn't care about anything." Correct 2: Going outside without a coat in subfreezing weather could be inferred as impaired judgment, which is consistent with opioid intoxication. Feedback 3: Rapid speech and hypervigilance are more consistent with stimulant intoxication. In opioid intoxication one would expect to see mental cloudiness. Correct 4: Impairment in attention and memory is consistent with opioid intoxication. Correct 5: Paula is describing pupillary constriction, which is consistent with opioid intoxication.

40. Which issues influence an individual's predisposition to substance-related disorders? Select all that apply. 1) Genetic history 2) Fixation at the oral stage of psychosexual development 3) Punitive ego 4) Personality traits 5) Behavior modeling

Correct 1: Research has indicated that an apparent hereditary factor is involved in the development of substance-use disorders. This is especially evident with alcoholism. Correct 2: Theories of psychosexual development state that anxiety in people fixated at the oral stage may be reduced by their consumption of substances such as alcohol. Feedback 3: A psychodynamic approach to the etiology of substance abuse focuses on a punitive superego, not ego. According to psychodynamic theory, individuals with punitive superegos turn to alcohol to diminish unconscious anxiety. Correct 4: Certain personality traits, such as low self-esteem, depression, and passivity, are thought to increase a tendency toward addictive behavior. Correct 5: Studies have shown that children and adolescents are more likely to use substances if they have parents who provide a model for substance use.

41. Paul, a 65-year-old Caucasian, is being seen at the health clinic for hypertension and has a history of alcohol use disorder. Which of the following observations by the nurse are consistent with physical complications associated with chronic alcohol use disorders? Select all that apply. 1) His skin is yellow. ) He has a butterfly-shaped rash on his cheeks and nose. 3) His abdomen is distended. 4) He is coughing up blood. 5) He complains of acute pain in his left eye.

Correct 1: Yellowish skin is evidence of jaundice, which is secondary to cirrhosis of the liver. Cirrhosis of the liver is a common manifestation of end-stage alcoholic liver disease. Feedback 2: Although facial flushing is a common manifestation in chronic alcohol use disorders, a distinctly butterfly-shaped rash may be indicative of other autoimmune conditions such as lupus erythematosis. Further assessment is warranted. Correct 3: Abdominal distention can be a manifestation of alcoholic hepatitis, cirrhosis of the liver, and pancreatitis, all of which are complications of alcohol use disorder. Further assessment is warranted. Correct 4: Coughing up blood may be evidence of several complications of alcoholism, including esophageal varices, which can culminate in potentially fatal hemorrhage. Further assessment is warranted to evaluate for these as well as other potential causes of coughing up blood. Feedback 5: A complaint of pain or pressure in or behind one's eyes is not directly associated with alcoholism but suggests a potentially emergent concern that requires further assessment.

A family member of a patient with delusions of persecution asks the nurse, "Are there any circumstances under which the treatment team is justified in violating a patient's right to confidentiality?" The nurse should reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

D

A newly admitted acutely psychotic patient is a private patient of the medical director and a private-pay patient. To whom does the psychiatric nurse assigned to the patient owe the duty of care? a. Medical director b. Hospital c. Profession d. Patient

D

A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation. a. Patient struck another patient who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two patients away from each other for 24 hours. b. Seclusion ordered by physician at 1415 after command hallucinations told the patient to hit another patient. Careful monitoring of patient maintained during period of seclusion. c. Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Patient calmer and apologized for outburst. d. Patient pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 patient yelled, "I'll punch anyone who gets near me," and struck another patient with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430.

D

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

D

Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer; more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others. d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."

D

A patient tells the nurse, "My doctor prescribed Paxil (paroxetine) for my depression. I assume I'll have side effects like I had when I was taking Tofranil (imipramine)." The nurse's reply should be based on the knowledge that paroxetine is a(n): a. selective norepinephrine reuptake inhibitor. b. tricyclic antidepressant. c. MAO inhibitor d. SSRI

D Paroxetine is an SSRI and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

A patient begins therapy with a phenothiazine medication. What teaching should the nurse provide related to the drug's strong dopaminergic effect? a. Chew sugarless gum b. Increase daily fiber c. Arise slowly from bed d. Report changes in muscle movement

D Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Movement disorders and motor abnormalities (extrapyramidal side effects), such as parkinsonism, akinesia, akathisia, dyskinesia, and tardive dyskinesia, are likely to occur early in the course of treatment. They are often heralded by sensations of muscle stiffness. Early intervention with antiparkinsonism medication can increase the patient's comfort and prevent dystonic reactions. The distracters are related to anticholinergic effects.

1. A patient asks, "What are neurotransmitters? The doctor said mine are imbalanced." Select the nurse's best response. a. "How do you feel about having imbalanced neurotransmitters?" b. "Neurotransmitters protect us from harmful effects of free radicals." c. "Neurotransmitters are substances we consume that influence memory and mood." d. "Neurotransmitters are natural chemicals that pass messages between brain cells."

D The patient asked for information, and the correct response is most accurate. Neurotransmitters are chemical substances that function as messengers in the central nervous system. They are released from the axon terminal, diffuse across the synapse, and attach to specialized receptors on the postsynaptic neuron. The distracters either do not answer the patient's question or provide untrue, misleading information.

32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

NS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.