Exam 2
A client says to the nurse: "I read an article about Alzheimer's and it said the disease is hereditary. My mother has Alzheimer's disease. Does that mean I'll get it when I'm old?" The nurse bases her response on the knowledge that which of the following factors is not associated with increased incidence of NCD due to Alzheimer's disease? a. Multiple small strokes b. Family history of Alzheimer's disease c. Head trauma d. Advanced age
A
A client with depression has just been prescribed the antidepressant phenelzine (Nardil). She says to the nurse, "The doctor says I will need to watch my diet while I'm on this medication. What foods should I avoid?" Which of the following is the correct response by the nurse? a. Blue cheese, red wine, raisins b. Black beans, garlic, pears c. Pork, shellfish, egg yolks d. Milk, peanuts, tomatoes
A
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
A
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.
A
A polysubstance abuser makes the statement, "The green and whites do me good after speed." How might the nurse interpret the statement? a. The client abuses amphetamines and anxiolytics. b. The client abuses alcohol and cocaine. c. The client is psychotic. d. The client abuses narcotics and marijuana.
A
Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Clint's belief is an example of a: a. Delusion of persecution b. Delusion of reference c. Delusion of control or influence d. Delusion of grandeur
A
Dan begins attendance at AA meetings. Which of the statements by Dan reflects the purpose of this organization? a. "They claim they will help me stay sober." b. "I'll dry out in AA, then I can have a social drink now and then." c. "AA is only for people who have reached the bottom." d. "If I lose my job, AA will help me find another."
A
Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job, states to the nurse, "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my coworkers." The defense mechanism that Dan is using is: a. Denial b. Projection c. Displacement d. Rationalization
A
In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? A. Risk for injury related to excessive hyperactivity B. Disturbed sleep pattern related to manic hyperactivity C. Imbalanced nutrition, less than body requirements related to inadequate intake D. Situational low self-esteem related to embarrassment secondary to high-risk behaviors
A
Joe, a Native American, appears at the community health clinic with an oozing stasis ulcer on his lower right leg. It is obviously infected, and he tells the nurse that the shaman has been treating it with herbs. The nurse determines that Joe needs emergency care, but Joe states he will not go to the emergency department (ED) unless the shaman is allowed to help treat him. How should the nurse handle this situation? a. Contact the shaman and have him meet them at the ED to consult with the attending physician. b.Tell Joe that the shaman is not allowed in the ED. c. Explain to Joe that the shaman is at fault for his leg being in the condition it is in now. d. Have the shaman try to talk Joe into going to the ED without him.
A
Maria is an Italian American who is in the hospital after having suffered a miscarriage at 5 months' gestation. Maria's mother says to the nurse, "If only Maria had told me she wanted the biscotti. I would have made them for her." What is the meaning behind Maria's mother's statement? a. Some Italian Americans believe a miscarriage can occur if a woman does not eat a food she craves. b. Some Italian Americans think biscotti can prevent miscarriage. c. Maria's mother is taking the blame for Maria's miscarriage. d. Maria's mother believes the physician should have told Maria to eat biscotti.
A
Mr. White is admitted to the hospital after an extended period of binge alcohol drinking. His wife reports that he has been a heavy drinker for a number of years. Lab reports reveal he has a blood alcohol level of 250 mg/dL. He is placed on the chemical addiction unit for detoxification. When would the first signs of alcohol withdrawal symptoms be expected to occur? a. Several hours after the last drink b.2 to 3 days after the last drink c. 4 to 5 days after the last drink d. 6 to 7 days after the last drink
A
The goal of cognitive therapy with depressed clients is to: a. Identify and change dysfunctional patterns of thinking. b.Resolve the symptoms and initiate or restore adaptive family functioning. c. Alter the neurotransmitters that are creating the depressed mood. d. Provide feedback from peers who are having similar experiences.
A
The physician orders lithium carbonate 600 mg tid for a newly diagnosed client with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. Therapeutic range for acute mania is: a. 1.0 to 1.5 mEq/L b.10 to 15 mEq/L c. 0.5 to 1.0 mEq/L d. 5 to 10 mEq/L
A
A client has just been admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which of the following behavioral manifestations might the nurse expect to assess? (Select all that apply.) a. Slumped posture b. Delusional thinking c. Feelings of despair d. Feels best early in the morning and worse as the day progresses e. Anorexia
A, B, C, E
Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? (Select all that apply.) a. Olanzepine (Zyprexa) b. Paroxetine (Paxil) c. Carbamazepine (Tegretol) d. Lamotrigine (Lamictal) e. Tranylcypromine (Parnate)
A, C, D
The nurse is prioritizing nursing diagnoses in the plan of care for a client experiencing a manic episode. Number the diagnoses in order of the appropriate priority. ____a. Disturbed sleep pattern AEB sleeping 4-5 hrs/night ____b. Risk for injury related to manic hyperactivity ____ c. Impaired social interaction AEB manipulation of others ____d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor
A-3 B-1 C-4 D-2
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
A. A list of all medications the person currently takes
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.
A. Remain safe in the environment
Which of the following medications have been indicated for improvement in cognitive functioning in mild to moderate Alzheimer's disease? (Select all that apply.) a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Risperidone (Risperdal) d. Sertraline (Zoloft) e. Galantamine (Razadyne)
A: Donepezil B Rivastigmine E: Galantamine
A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? A. Identify with the person speaking B. Imitate the nurse's movements C. Alleviate alogia D. Alleviate avolition
A: Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.
In addition to disturbances in cognition and orientation, individuals with Alzheimer's disease may also show changes in which of the following? (Select all that apply.) a. Personality b. Vision c. Speech d. Hearing e. Mobility
A: Personality C: Speech E: Mobility
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."
B
A newly admitted depressed client isolates herself in her room and just sits and stares into space. How best might the nurse begin an initial therapeutic relationship with this client? a. Say, "Come with me. I will go with you to group therapy." b. Make frequent short visits to her room and sit with her. c. Offer to introduce her to the other clients. d. Help her to identify stressors in her life that precipitate crises.
B
A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia
B
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)
B
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
B
A suicidal client, with a history of manic behavior, is admitted to the ED. The client's diagnosis is documented as bipolar I disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder? A. The physician does not believe the client is suffering from major depression. B. The client has experienced a manic episode in the past. C. The client does not exhibit psychotic symptoms. D. There is no history of major depression in the client's family.
B
Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job, states to the nurse, "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my coworkers." The nurse's best response is: a. "Maybe your boss is mistaken, Dan." b. "You are here because your drinking was interfering with your work, Dan." c. "Get real, Dan! You're a boozer and you know it!" d. "Why do you think your boss sent you here, Dan?"
B
From which of the following symptoms might the nurse identify a chronic cocaine user? a. Clear, constricted pupils b. Red, irritated nostrils c. Muscle aches d. Conjunctival redness
B
Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the emergency department by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of: a. A delusion of grandeur b. A delusion of persecution c. A delusion of reference d. A delusion of control or influence
B
Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sisterin-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is: a. Imbalanced nutrition: less than body requirements related to not eating b. Risk for injury related to hyperactivity c. Disturbed sleep pattern related to agitation d. Ineffective coping related to denial of depression
B
Maria is an Italian American who is in the hospital after having suffered a miscarriage at 5 months' gestation. Her room is filled with relatives who have brought a variety of foods and gifts for Maria. They are all talking, seemingly at the same time, and some, including Maria, are crying. They repeatedly touch and hug Maria and each other. How should the nurse handle this situation? a. Explain to the family that Maria needs her rest and they must all leave. b. Allow the family to remain and continue their activity as described, as long as they do not disturb other clients. c. Explain that Maria will not get over her loss if they keep bringing it up and causing her to cry so much. d. Call the family priest to come and take charge of this family situation.
B
Mr. Stone is a client in the hospital with a diagnosis of vascular NCD. In explaining this disorder to Mr. Stone's family, which of the following statements by the nurse is correct? a. "He will probably live longer than if his disorder was of the Alzheimer's type." b. "Vascular NCD shows step-wise progression. This is why he sometimes seems okay." c. "Vascular NCD is caused by plaques and tangles that form in the brain." d. "The cause of vascular NCD is unknown."
B
Sarah is an African American woman who receives a visit from the psychiatric home health nurse. A referral for a mental health assessment was made by the public health nurse, who noticed that Sarah was becoming exceedingly withdrawn. When the psychiatric nurse arrives, Sarah says to her, "No one can help me. I was an evil person in my youth, and now I must pay." How might the nurse assess this statement? a. Sarah is having delusions of persecution. b. Some African Americans believe illness is God's punishment for their sins. c. Sarah is depressed and just wants to be left alone. d. African Americans do not believe in psychiatric help.
B
The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes these behaviors as a symptom of the client's illness. The most appropriate nursing intervention for this symptom is to: a. Ask the client to describe his physical symptoms. b. Ask the client to describe what he is hearing. c. Administer a dose of benztropine. d. Call the physician for additional orders.
B
The nurse must give Frank, a Latino American, a physical examination. She tells him to remove his clothing and put on an examination gown. Frank refuses. How should the nurse interpret this behavior? a. Frank does not believe in taking orders from a woman. b. Frank is modest and embarrassed to remove his clothes. c. Frank doesn't understand why he must remove his clothes. d. Frank does not think he needs a physical examination.
B
The physician orders sertraline (Zoloft) 50 mg PO bid for Margaret, a 68-year-old woman with major depressive disorder. After 3 days of taking the medication, Margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better." What is the most appropriate response by the nurse? a. "Cheer up, Margaret. You have so much to be happy about." b. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms." c. "I'll report that to the physician, Margaret. Maybe he will order something different." d. "Try not to dwell on your symptoms, Margaret. Why don't you join the others down in the dayroom?"
B
The primary goal in working with an actively psychotic, suspicious client would be to: a. Promote interaction with others. b. Decrease his anxiety and increase trust. c. Improve his relationship with his parents. d. Encourage participation in therapy activities.
B
Tony, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Tony is to: a. Give him an injection of Thorazine. b. Ensure a safe environment for him and others. c. Place him in restraints. d. Order him a nutritious diet.
B
Which of the following medications is the physician most likely to order for a client experiencing alcohol withdrawal syndrome? a. Haloperidol (Haldol) b. Chlordiazepoxide (Librium) c. Methadone (Dolophine) d. Phenytoin (Dilantin
B
Which psychiatric diagnosis is common within the Native American culture? a. Schizophrenia b. Alcohol use disorder c. Posttraumatic stress disorder d. Impulse control disorder
B
In teaching a client about his antidepressant medication, fluoxetine, which of the following would the nurse include? (Select all that apply.) a. Don't eat chocolate while taking this medication. b. Keep taking this medication, even if you don't feel it is helping. It sometimes takes a while to take effect. c. Don't take this medication with the migraine drugs "triptans." d. Go to the lab each week to have your blood drawn for therapeutic level of this drug. e. This drug causes a high degree of sedation, so take it just before bedtime.
B, C
Mrs. G, who has NCD due to Alzheimer's disease, says to the nurse, "I have a date tonight. I always have a date on Christmas." Which of the following is the most appropriate response? a. "Don't be silly. It's not Christmas, Mrs. G." b. "Today is Tuesday, Oct. 21, Mrs. G. We will have supper soon, and then your daughter will come to visit." c. "Who is your date with, Mrs. G?" d. "I think you need some more medication, Mrs. G. I'll bring it to you now."
B: "Today is tuesday, oct. 21, Mrs. G. We will have supper soon, and then your daughter will come to visit"
Mrs. G, who has NCD due to Alzheimer's disease, has trouble sleeping and wanders around at night. Which of the following nursing actions would be best to promote sleep in Mrs. G? a. Ask the doctor to prescribe flurazepam (Dalmane). b. Ensure that Mrs. G gets an afternoon nap so she will not be overtired at bedtime. c. Make Mrs. G a cup of tea with honey before bedtime. d. Ensure that Mrs. G gets regular physical exercise during the day.
B: ensure that Mrs. G gets an afternoon nap so she will not be overtired at bedtime
Mrs. G has been diagnosed with NCD due to Alzheimer's disease. The primary nursing intervention in working with Mrs. G is which of the following? a. Ensuring that she receives food she likes, to prevent hunger b. Ensuring that the environment is safe, to prevent injury c. Ensuring that she meets the other patients, to prevent social isolation d. Ensuring that she takes care of her own ADLs, to prevent dependence
B: ensuring that the environment is safe, to prevent injury
A child with bipolar disorder also has attention-deficit/hyperactivity disorder (ADHD). How would these co-morbid conditions most likely be treated? a. No medication would be given for either condition. b. Medication would be given for both conditions simultaneously. c. The bipolar condition would be stabilized first before medication for the ADHD would be given. d. The ADHD would be treated before consideration of the bipolar disorder.
C
A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell the client she cannot wear this outfit while she is in the hospital. b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit she must remain in her room.
C
A client whose husband died 6 months ago is diagnosed with major depressive disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a. "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response." d. "Just think about the good times that you had while he was alive."
C
Dan has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job. Dan's drinking buddies come for a visit, and when they leave, the nurse smells alcohol on Dan's breath. Which of the following would be the best intervention with Dan at this time? a. Search his room for evidence. b. Ask, "Have you been drinking alcohol, Dan?" c. Send a urine specimen from Dan to the lab for drug screening. d. Tell Dan, "These guys cannot come to the unit to visit you again."
C
Frank is a Latino American who has an appointment at the community health center for 1 p.m. The nurse is angry when Frank shows up at 3:30 p.m. stating, "I was visiting with my brother." How might the nurse best interpret this behavior? a. Frank is being passive-aggressive by showing up late. b. This is Frank's way of defying authority. c. Frank is a member of a cultural group that is present-time oriented. d. Frank is a member of a cultural group that rejects traditional medicine.
C
Margaret, age 68, is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with major depressive disorder. The priority nursing diagnosis for Margaret would be: a. Imbalanced nutrition: less than body requirements b. Complicated grieving c. Risk for suicide d. Social isolation
C
Margaret, age 68, is diagnosed with bipolar I disorder, current episode manic. She is extremely hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to: a. Sit with her during meals to ensure that she eats everything on her tray. b. Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." d. Tell Margaret that she will be on room restriction until she starts gaining weight.
C
Miss Lee is an Asian American on the psychiatric unit. She tells the nurse, "I must have the hot ginger root for my headache. It is the only thing that will help." What meaning does the nurse attach to this statement by Miss Lee? a. She is being obstinate and wants control over her care. b.She believes that ginger root has magical qualities. c. She subscribes to the restoration of health through the balance of yin and yang. d. Asian Americans refuse to take traditional medicine for pain.
C
Sarah is an African American woman who lives in the rural South. She receives a visit from the public health nurse. Sarah says to the nurse, "Granny told me to eat a lot of poke greens and I would feel better." How should the nurse interpret this statement? a.Sarah's grandmother believes in the healing power of poke greens. b. Sarah believes everything her grandmother tells her. c. Sarah has been receiving health care from a "folk practitioner." d. Sarah is trying to determine if the nurse agrees with her grandmother.
C
Symptoms of alcohol withdrawal include: a. Euphoria, hyperactivity, and insomnia b. Depression, suicidal ideation, and hypersomnia c. Diaphoresis, nausea and vomiting, and tremors d. Unsteady gait, nystagmus, and profound disorientation
C
The night nurse finds Mrs. G, a client with Alzheimer's disease, wandering the hallway at 4 a.m. and trying to open the door to the side yard. Which statement by the nurse probably reflects the most accurate assessment of the situation? a. "That door leads out to the patio, Mrs. G. It's nighttime. You don't want to go outside now." b. "You look confused, Mrs. G. What is bothering you?" c. "This is the patio door, Mrs. G. Are you looking for the bathroom?" d. "Are you lonely? Perhaps you'd like to go back to your room and talk for a while."
C
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
C
The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Why is chlorpromazine ordered? a. To reduce extrapyramidal symptoms b. To prevent neuroleptic malignant syndrome c. To decrease psychotic symptoms d. To induce sleep
C
The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing: a. Somatic delusions b. Catatonic stupor c. Auditory hallucinations d. Pseudoparkinsonism
C
When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? a. Provide large motor activities to relieve the client's pent-up tension. b. Administer a dose of prn chlorpromazine to keep the client calm. c. Call for sufficient help to control the situation safely. d. Convey to the client that his behavior is unacceptable and will not be permitted
C
Which finding constitutes a negative symptom associated with schizophrenia? a) Hostility b) Bizarre behavior c) Poverty of thought d) Auditory hallucinations
C
Which value of the Northern European American culture should a nursing instructor include when teaching about cultural diversity? A. Northern European Americans are present oriented. B. Northern European Americans are highly religious, and church attendance is critical. C. Northern European Americans value punctuality and efficiency. D. Northern European Americans emphasize family cohesiveness due to increased technology.
C
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
C. communication deficits
A client is admitted with a diagnosis of brief psychotic disorder with catatonic features. Which symptoms are associated with the catatonic specifier? A. Strong ego boundaries and abstract thinking B. Ataxia and akinesia C. Stupor, muscle rigidity, and negativism D. Substance abuse and cachexia
C: Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors.
Which of the following interventions is most appropriate in helping a client with Alzheimer's disease with her ADLs? (Select all that apply.) a. Perform ADLs for her while she is in the hospital. b. Provide her with a written list of activities she is expected to perform. c. Assist her with step-by-step instructions. d. Tell her that if her morning care is not completed by 9 a.m. it will be performed for her by the nurse's aide so that she can attend group therapy. e. Encourage her and give her plenty of time to perform as many of her ADLs as possible independently.
C: assist her with step-by-step instructions E: encourage her and give her plenty of time to perform as many of her ADL's as possible independently
An example of a treatable (reversible) form of neurocognitive disorder (NCD) is one that is caused by which of the following? (Select all that apply.) a. Multiple sclerosis b. Multiple small brain infarcts c. Electrolyte imbalances d. HIV disease e. Folate deficiency
C: electrolyte imbalances E: Folate deficiency
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."
D
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?"
D
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.
D
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
D
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.
D
An individual who is addicted to heroin is likely to experience which of the following symptoms of withdrawal? a. Increased heart rate and blood pressure b. Tremors, insomnia, and seizures c. Incoordination and unsteady gait d. Nausea and vomiting, diarrhea, and diaphoresis
D
As a child, Joe was physically abused by his father. The father is now dying and has expressed a desire to see his son before he dies. Joe is depressed and says to the mental health nurse, "I'm so angry! Why did God have to give me a father like this? I feel cheated of a father! I've always been a good person. I deserved better. I hate God!" From this subjective data, which nursing diagnosis might the nurse apply to Joe? a. Readiness for enhanced religiosity b. Risk for impaired religiosity c. Readiness for enhanced spiritual well-being d. Spiritual distress
D
Clint, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: a. "That's ridiculous, Clint. No one is going to hurt you." b. "The CIA isn't interested in people like you, Clint." c. "Why do you think the CIA wants to kill you?" d. "I know you believe that, Clint, but it's really hard for me to believe."
D
Education for the client who is taking MAOIs should include which of the following? a. Fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity b. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks c. Short-term use, possible tolerance to beneficial effects, careful tapering of the drug at end of treatment d. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification
D
Joe, a Native American, goes to the emergency department (ED) because he has an oozing stasis ulcer on his leg. He is accompanied by the tribal shaman, who has been treating Joe on the reservation. As a greeting, the physician extends his hand to the shaman, who lightly touches the physician's hand, then quickly moves away. How should the physician interpret this gesture? a. The shaman is snubbing the physician. b. The shaman is angry at Joe for wanting to go to the ED. c. The shaman does not believe in traditional medicine. d. The shaman does not feel comfortable with touch.
D
John is a client at the mental health clinic. He is depressed, has been expressing suicidal ideations, and has been seeing the psychiatric nurse every 3 days. He has been taking 100 mg of sertraline daily for about a month, receiving small amounts of the medication from his nurse at each visit. Today he comes to the clinic in a cheerful mood, much different than he seemed just 3 days ago. How might the nurse assess this behavioral change? a. The sertraline is finally taking effect. b. He is no longer in need of antidepressant medication. c. He has completed the grief response over loss of his wife. d. He may have decided to carry out his suicide plan
D
Miss Lee, an Asian American on the psychiatric unit, says she is afraid that no one from her family will visit her. On what belief does Miss Lee base her statement? a.Many Asian Americans do not believe in hospitals. b. Many Asian Americans do not have close family support systems. c. Many Asian Americans believe the body will heal itself if left alone. d. Many Asian Americans view psychiatric problems as bringing shame to the family.
D
The most common comorbid condition in children with bipolar disorder is: a. Schizophrenia b. Substance disorders c. Oppositional defiant disorder d. Attention-deficit/hyperactivity disorder
D
The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Because benztropine was ordered on a prn basis, which of the following assessments by the nurse would convey a need for this medication? a. The client's level of agitation increases. b. The client complains of a sore throat. c. The client's skin has a yellowish cast. d. The client develops tremors and a shuffling gait.
D
The primary focus of family therapy for clients with schizophrenia and their families is: a. To discuss concrete problem solving and adaptive behaviors for coping with stress b. To introduce the family to others with the same problem c. To keep the client and family in touch with the health care system d. To promote family interaction and increase understanding of the illness
D
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
D. Maintenance of nutrition and hydration
Mrs. G has been diagnosed with NCD due to Alzheimer's disease. The cause of this disorder is which of the following? a. Multiple small brain infarcts b.Chronic alcohol abuse c. Cerebral abscess d. Unknown
D: unknown
The symptoms of _____________ usually begin quite abruptly and often are reversible and brief.
Delirium
_______________ is a disturbance of awareness and a change in cognition that develop rapidly over a short period. Level of consciousness is often affected and psychomotor activity may fluctuate between agitated purposeless movements and a vegetative state resembling catatonic stupor.
Delirium
____________________ may be caused by a general medical condition, substance intoxication or withdrawal, or ingestion of a medication or exposure to a toxin.
Delirium
Symptoms of _____________ are insidious and develop slowly over time. In most clients, the disorder runs a progressive, irreversible course.
NCD/ Dementia
______________ may be caused by genetics, cardiovascular disease, infections, neurophysiological disorders, and other general medical conditions.
NCD/ Dementia
Joe, who has come to the mental health clinic with symptoms of depression, says to the nurse, "My father is dying. I have always hated my father. He physically abused me when I was a child. We haven't spoken for many years. He wants to see me now, but I don't know if I want to see him." With which spiritual need is Joe struggling? a. Forgiveness b. Faith c. Hope d. Meaning and purpose in life
a
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.
a. Label the bathroom door
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
b. Confabulation
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.
b. Focus interaction on familiar topics
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."
d. "It is disappointing when someone you love no longer recognizes you."
Objectives of care for the client experiencing a chronic, progressive disorder are aimed at preserving the ____________ of the individual, promoting deceleration of the symptoms, and ________________ functional capabilities.
dignity maximizing functional capabilities
Objectives of care for the client experiencing an acute syndrome are aimed at eliminating the ____________, promoting client ____________, and returning to the highest possible level of functioning.
eliminate the cause promote client safety
