Exam 2 Practice Questions

When caring for a withdrawn, reclusive, psychotic client, the priority goal is for the client to develop: 1. Trust 2. Self-worth 3. A sense of identity 4. Improved social skills

1. Trust Trust is basic to all therapies; without trust a therapeutic relationship cannot be established.

A hyperactive self-destructive child is to be discharged from an inpatient setting in a few days. In preparation for the child's discharge, it is most important for the nurse to plan to: 1. Establish, maintain, and enforce limits on behavior 2. Meet with child's teacher to review child's needs 3. Schedule a team conference with child and parents 4. Help child to begin terminating relationship with nursing staff

3. Schedule a team conference with child & parents This provides an opportunity for the team, the child, and the parents to interact in a therapeutic environment.

The nurse finds a client with schizophrenia lying under a bench in the hall. The client states, "God told me to lie here." What is the best response by the nurse? 1. "I didn't hear anyone talking. Come with me to your room." 2."What you heard was in your head; it was your imagination." 3."Come to the dayroom and watch television. It will help take your mind off of this." 4."God would not tell you to do that, he wants you to behave reasonably."

1. "I didn't hear anyone talking. Come with me to your room." The nurse is focusing on reality and trying to distract and refocus the client's attention.

The nurse manager is evaluating a primary nurse who is working with a hospitalized adolescent client with the diagnosis of conduct disorder. Which intervention by the primary nurse should the nurse manger question? 1. Discussing rules of the unit 2. Allows opportunities for choices 3. Explaining the consequences for not following unit regulations 4. Encouraging the verbalization of negative feelings toward others

1. Discussing rules of the unit (The environment must be consistent and predictable to limit manipulative behavior.)

Frontal lobe deficits in schizophrenia are thought to be responsible for: 1. Disorganized thinking 2. Hallucinations 3. Depression 4. Parkinsonism

1. Disorganized thinking Good. The frontal lobe is responsible for organized thinking. If there are deficits or alterations in this region, disorganized thinking will result.

When assessing the mental status of a 7- or 8-year-old child, it is most important for the nurse to: 1. Listen to the parent's description of the child's behvior 2. Compare the child's functioning from one day to another 3. Engage parents in a discussion about the child's feelings 4. Determine the child's mental status by using direct questions

2. Compare the child's functioning from one day to another Comparison over time is the only way for the nurse to accurately assess the mental status of a child.

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1. Parkinsonism 2. Tardive Dyskinesia 3. Hypertensive crisis 4. Neuroleptic

2. Tardive Dyskinesia Good. Tardive dyskinesia is a reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Parkinsonism is characterized by tremors, masklike facies, rigidity, and a shuffling gait. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity.

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you" 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent out to hurt you?"

3. "Do you feel afraid that people are trying to hurt you?" It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

A nurse teaches a client about the side effects and precautions associated with the typical antipsychotic haloperidol (Haldol). The nurse evaluates that the teaching is understood when the client states: 1. "I will immediately report any diarrhea or vomiting to my doctor." 2. "I will not eat any tyramine-containing foods while I'm taking this drug." 3. "I'll avoid direct sunlight and use a sunscreen product when I go outdoors." 4. "I'll maintain an adequate fluid intake because I may urinate more than usual."

3. "I'll avoid direct sunlight and use a sunscreen product when I go outdoors." Photosensitivity is a side effect of many antipsychotic medications. 1. These adaptations are side effects of lithium, not Haldol. 2. Avoiding tyramine-containing foods is a precaution associated with MAO inhibitors, not Haldol. 4. This is a precaution associated with lithium, not Haldol.

A child with ADHD had this nursing diagnosis: impaired social interaction, related to excessive neuronal activity, as evidenced by aggressiveness and dysfunctional play with others. Which finding indicates the plan of care was effective? 1. Improved ability to identify anxiety and use self-control strategies 2. Increased expressiveness in communication with others 3. Engages in cooperative play with other children 4. Increased responsiveness to authority figures

3. Engages in cooperative play with other children

A nurse is assessing an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience? 1. Paranoid delusions and hypervigilance 2. Depression and psychomotor retardation 3. Loosened associations and hallucinations 4. Ritualistic behaviors and obsessive thinking

3. Loosened associations and hallucinations Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia. Paranoid delusions and hypervigilance are more common in paranoid-type schizophrenia than in the undifferentiated type. Depression and psychomotor retardation are not characteristic of schizophrenia. Ritualistic behavior and obsessive thinking generally are associated with obsessive-compulsive disorders, not schizophrenia.

The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do." Good. The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Have the client sign a release of information to appropriate parties for assessment purposes. 2. Begin to educate the client about social supports in the community. 3. Increase socialization of the client with peers. 4. Avoid laughing or whispering in front of the client.

4. Avoid laughing or whispering in front of the client Good. Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

To help a disturbed, acting-out child develop a trusting relationship, the nurse should: 1. Inquire as to the child's feelings about the parents 2. Implement a half hour one-to-one interaction daily 3. Initiate limit setting and explain the rules to be followed 4. Offer periodic support and emphasize safety in play activities

4. Offer periodic support and emphasize safety in play activities This action sets a foundation for trust because it allows the child to see that the nurse cares.

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet Count 2. Blood Glucose 3. Liver Function Tests 4. White Blood Cell Count

4. White Blood Cell Count A client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 cells/mm3. Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.