Mental health ch 1-28

A bill introduced in Congress would reduce funding for the care of people with mental illnesses. A group of nurses write letters to their elected representatives in opposition to the legislation. Which role have the nurses fulfilled?

Advocacy 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 patient in the emergency department reports, "I hear voices saying someone is stalking me. They want to kill me because I found the cure for cancer. I will stab anyone that threatens me." Which aspects of mental health have the greatest immediate concern to a nurse? Select all that apply.

Appraisal of reality Control over behavior Healthy self-concept The aspects of mental health of greatest concern are the patient's appraisal of and control over behavior. The patient's appraisal of reality is inaccurate, and auditory hallucinations are evident, as well as delusions of persecution and 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. Data are not present to suggest that the other aspects of mental health (happiness and effectiveness in work) are of immediate concern.

A nurse explains multiaxial diagnoses to a psychiatric technician. Which information is accurate?

Assessments of several aspects of functioning are included. The use of five axes requires an assessment beyond the diagnosis of a mental disorder and includes relevant medical conditions, psychosocial and environmental problems, and global assessment of functioning. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) is not a template for treatment planning and does not use a specific biopsychosocial theory. Nursing diagnoses are not included in multiaxial diagnoses.

A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, "No!" when given direction. The nurse's counseling with the parent should be based on the premise that the child is engaged in which of Erikson's psychosocial crises?

Autonomy versus Shame and Doubt The crisis of Autonomy versus Shame and Doubt is related to the developmental task of gaining control of self and environment, as exemplified by toilet training. This psychosocial crisis occurs during the period of early childhood. Trust versus Mistrust is the crisis of the infant, Initiative versus Guilt is the crisis of the preschool and early school-aged child, and Industry versus Inferiority is the crisis of the 6- to 12-year-old child.

A patient comments, "I never know the right answer" and "My opinion is not important." Using Erikson's theory, which psychosocial crisis did the patient have difficulty resolving?

Autonomy versus Shame and Doubt These statements show severe self-doubt, indicating that the crisis of gaining control over the environment is not being successfully met. Unsuccessful resolution of the crisis of Initiative versus Guilt results in feelings of guilt. Unsuccessful resolution of the crisis of Trust versus Mistrust results in poor interpersonal relationships and suspicion of others. Unsuccessful resolution of the crisis of Generativity versus Self-Absorption results in self-absorption that limits the ability to grow as a person.

A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should prepare to teach the patient about a medication from which group?

Benzodiazepines Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Anticonvulsants are used to treat bipolar disorder or seizures. Antipsychotic drugs are used to treat psychosis.

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?

Clinical algorithm 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 patient has dementia. The health care provider wants to make a differential diagnosis between Alzheimer disease and multiple infarctions. Which diagnostic procedure should a nurse expect to prepare the patient for first?

Computed tomography (CT) scan CT scan shows the presence or absence of structural changes, including cortical atrophy, ventricular enlargement, and areas of infarction—information that will be helpful to the health care provider. The other tests focus on brain activity and are more expensive; they may be ordered later.

A patient has delusions and hallucinations. Before beginning treatment with a psychotropic medication, the health care provider wants to rule out the presence of a brain tumor. For which test will a nurse need to prepare the patient?

Computed tomography (CT) scan or magnetic resonance imaging (MRI) CT scan and an MRI visualize neoplasms and other structural abnormalities. A PET scan, SPECT scan, and fMRI, which give information about brain function, are not indicated. An arteriogram would not be appropriate.

A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse consult to discern the criteria used to establish this diagnosis?

DSM-IV-TR The DSM-IV-TR gives the criteria used to diagnose each mental disorder. The Nursing Diagnosis Manual focuses on nursing diagnoses. A psychiatric nursing textbook or behavioral health reference manual may not contain diagnostic criteria.

A nurse wants to find a description of diagnostic criteria for a person with schizophrenia. Which resource should the nurse consult?

DSM-IV-TR The DSM-IV-TR identifies diagnostic criteria for psychiatric diagnoses. The other sources have useful information but are not the best resources for finding a description of the diagnostic criteria for a psychiatric disorder.

A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action?

Dopamine-blocking effects Medications that block dopamine often produce disturbances of movement such as akathisia because dopamine affects neurons involved in both the 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.

A patient's history shows intense and unstable relationships with others. The patient initially idealizes an individual and then devalues the person when the patient's needs are not met. Which aspect of mental health is a problem?

Fulfilling relationships The information provided centers on relationships with others, which 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.

A nurse listens to a group of recent retirees. One says, "I volunteer with Meals on Wheels, coach teen sports, and do church visitation." Another laughs and says, "I'm too busy taking care of myself to volunteer. I don't have time to help others." These comments contrast which developmental tasks?

Generativity versus Self-Absorption Both retirees are in middle adulthood, when the developmental crisis to be resolved is Generativity versus Self-Absorption. One exemplifies generativity; the other embodies self-absorption. The developmental crisis of Trust versus Mistrust would show a contrast between relating to others in a trusting fashion and being suspicious and lacking trust. Failure to negotiate the developmental crisis of Industry versus Inferiority would result in a sense of inferiority or difficulty learning and working as opposed to the ability to work competently. Behaviors that would be contrasted in the crisis of Intimacy versus Isolation would be emotional isolation and the ability to love and commit to oneself.

Operant conditioning will be used to encourage speech in a child who is nearly mute. Which technique would a nurse include in the treatment plan?

Give the child a small treat for speaking. Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards to reinforce speech. Ignoring the child will not change the behavior. Having the child observe others describes modeling. Teaching relaxation techniques and then coaxing speech is an example of systematic desensitization.

A patient asks a nurse, "The pamphlet I read about depression says psychosocial factors influence depression. What does that mean?" Which examples could the nurse cite to support the information? Select all that apply.

Having a hostile family Having an over- or underinvolved family Experiencing the sudden death of a parent or loved one Feeling strong guilt over having an abortion when one's religion forbids it Family influence is considered a psychosocial factor affecting a patient's mental health. A hostile under- or overinvolved family is critical of the patient and contributes to low self- esteem. Religious influences are considered psychosocial in nature. Life experiences, especially crises and losses, are considered psychosocial influences on mental health. Having two first-degree relatives with bipolar disorder would be considered a factor that influences the individual's risk for mental disorder, but it is a genetic, not psychosocial, factor. Treatment with a biological agent such as an antidepressant medication is an example of a biological influence.

Which historical nursing leader helped focus practice to recognize the importance of science in psychiatric nursing?

Hildegard Peplau Although all these leaders included science as an important component of practice, Hildegard Peplau most influenced its development in psychiatric nursing. Maslow was not a nurse, but his theories influence how nurses prioritize problems and care. Bailey wrote a textbook in the 1930s on psychiatric nursing interventions. Kris Martinsen emphasized the importance of caring in nursing practice.

Which documentation of diagnosis would a nurse expect for a person mental illness?

I Generalized anxiety disorder II Avoidant personality disorder III Fibromyalgia IV Declared bankruptcy 6 months ago V 60 The option beginning with a diagnosis of generalized anxiety disorder places a clinical disorder on Axis I, a personality disorder on Axis II, a medical problem on Axis III, a psychosocial problem on Axis IV, and global assessment of functioning (GAF) on Axis V. The other options misplace and incorrectly order the clinical data.

A 4-year-old child grabs toys from siblings, saying, "I want that toy now!" The siblings cry, and the child's parent becomes upset with the behavior. Using the Freudian theory, a nurse can interpret the child's behavior as a product of impulses originating in the

I'd The id operates on the pleasure principle, seeking immediate gratification of impulses. The ego acts as a mediator of behavior and weighs the consequences of the action, perhaps determining that taking the toy is not worth the parent's wrath. The superego would oppose the impulsive behavior as "not nice." The preconscious is a level of awareness.

A psychiatric nurse addresses Axis I of the DSM-IV-TR as the focus of care but also considers the presence of other long-term, nonmedical disorders that may affect treatment. To which axis should the nurse refer for this information?

II Axis II refers to personality disorders and mental retardation. Together, Axis I and Axis II constitute the classification of abnormal behavior diagnosed in the individual. Axis III indicates any relevant general medical conditions. Axis IV reports psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis. Axis V is the GAF score.

A person tells a nurse, "I was the only survivor in a small plane crash, but three business associates died. I got anxious and depressed and saw a counselor three times a week for a month. We talked about my feelings related to being a survivor, and now I'm fine, back to my old self." Which type of therapy was used?

Interpersonal therapy Interpersonal therapy returns the patient to the former level of functioning by helping the patient come to terms with the loss of friends and guilt over being a survivor. Milieu therapy refers to environmental therapy. Psychoanalysis calls for a long period of exploration of unconscious material. Behavior modification focuses on changing a behavior rather than helping the patient understand what is going on in his or her life.

A nurse surveys the medical records for violations of patients' rights. Which finding signals a violation?

No treatment plan is present in record. The patient has the right to have a treatment plan. Inspecting a patient's belongings is a safety measure. Patients have the right to a safe environment, including the right to be protected against impulses to harm self that occur as a result of a mental disorder.

A patient has anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter?

Norepinephrine Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight" response. 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 nurse says, "When I was in school I learned to call upset patients by name to get their attention, but I read a descriptive research study that says that this approach doesn't work. I'm going stop calling patients by name." Which statement is the best appraisal of this nurse's comment?

One descriptive research study rarely provides enough evidence to change practice. 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 flow charts 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.

A nurse assesses that a patient is suspicious and frequently manipulates others. Using the Freudian theory, these traits are related to which psychosexual stage?

Oral According to Freud, each of the behaviors mentioned develops as the result of attitudes formed during the oral stage, when an infant first learns to relate to the environment. Anal stage traits include stinginess, stubbornness, orderliness, or their opposites. Phallic stage traits include flirtatiousness, pride, vanity, difficulty with authority figures, and difficulties with sexual identity. Genital stage traits include the ability to form satisfying sexual and emotional relationships with members of the opposite sex, emancipation from parents, and a strong sense of personal identity.

An adult expresses the wish to be taken care of and often behaves in a helpless fashion. This adult has needs related to which of Freud's stages of psychosexual development?

Oral According to Freud, fixation at the oral stage sometimes produces dependent infantile behaviors in adults. Latency fixations often result in a difficulty identifying with others and developing social skills, resulting in a sense of inadequacy and inferiority. Phallic fixations result in having difficulty with authority figures and poor sexual identity. Anal fixation sometimes results in retentiveness, rigidity, messiness, destructiveness, and cruelty

A 26-month-old child displays negative behavior, refuses toilet training, and often shouts, "No!" when given directions. Using Freud's stages of psychosexual development, a nurse would assess the child's behavior is based on which stage?

Oral In Freud's stages of psychosexual development, the anal stage occurs from age 1 to 3 years and has, as its focus, toilet training and learning to delay immediate gratification. The oral stage occurs between birth and 1 year, the phallic stage occurs between 3 and 5 years, and the genital stage occurs between 13 and 20 years.

The parent of an adolescent with schizophrenia asks a nurse, "My child's doctor ordered a positron-emission tomography (PET) scan. What is that?" Select the nurse's best reply.

PET is a special scan that shows blood flow and activity in the brain." The parent is seeking information about PET scans. It is important to use terms the parent can understand. The correct option is the only reply that provides factual information relevant to PET scans. The incorrect responses describe magnetic resonance imaging (MRI), computed tomographic (CT) scans, and electroencephalography (EEG).

A nurse prepares to administer an antipsychotic medication to a patient with schizophrenia. Additional monitoring of the medication's effects and side effects will be most important if the patient is also diagnosed with which health problem? Select all that apply.

Parkinson disease Epilepsy Diabetes Antipsychotic medications may produce weight gain, which complicates the care of a patient with diabetes or lowers the seizure threshold or both, which complicates the care of a patient with epilepsy. Parkinson disease involves changes in transmission of dopamine and acetylcholine; therefore these drugs also complicate the care of a patient with the disorder. Osteoarthritis and Graves disease should have no synergistic effect with this medication.

In the majority culture of the United States, which individual is at greatest risk to be incorrectly labeled mentally ill?

Person who attends a charismatic church and describes hearing God's voice Hearing voices is generally associated with mental illness; however, in charismatic religious groups, hearing the voice of God or a prophet is a desirable event. In this situation, cultural norms vary, making it more difficult to make an accurate DSM-IV-TR diagnosis. The individuals described in the other options are less likely to be labeled as mentally ill.

A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain?

Prefrontal cortex The prefrontal cortex is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

An individual is experiencing problems associated with memory. Which cerebral structures are most likely to be involved in this deficit? Select all that apply.

Prefrontal cortex Temporal lobe Parietal lobe The prefrontal cortex, parietal, and temporal lobes of the cerebrum play a key role in the storage and processing of memories. The occipital lobe is predominantly involved with vision. The basal ganglia influence the integration of physical movement, as well as some thoughts and emotions.

A patient underwent psychotherapy weekly for 3 years. The therapist used free association, dream analysis, and facilitated transference to help the patient understand unconscious processes and foster personality changes. Which type of therapy was used?

Psychoanalysis The therapy described is traditional psychoanalysis. Short-term dynamic psychotherapy would last less than 1 year. Neither transactional analysis nor cognitive therapy makes use of the techniques described.

A nurse administers a medication that potentiates the action of gamma- aminobutyric acid (GABA). Which finding would be expected?

Reduced anxiety Increased levels of GABA reduce anxiety, thus any potentiation of GABA action should result in anxiety reduction. Memory enhancement is associated with acetylcholine and substance P. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

A patient begins therapy with a phenothiazine medication. What teaching should a nurse provide related to the drug's strong dopaminergic effect?

Report muscle stiffness. Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Dystonia is likely to occur early in the course of treatment and is often heralded by sensations of muscle stiffness. Early intervention with an antiparkinsonian medication can increase the patient's comfort and prevent dystonic reactions.

Priority teaching for a patient taking clozapine (Clozaril) should include which instruction?

Report sore throat and fever immediately. 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 administration.

A mentally ill person's current global assessment of functioning (GAF) score is 10. Select the nurse's highest priority related to this patient's care.

Safety This low GAF score indicates a consistent risk for self-harm exists; therefore the nurse's highest priority is safety.

A nurse supports parental praise of a child who is behaving in a helpful way. When the individual behaves with politeness and helpfulness in adulthood, which feeling will most likely result?

Self-esteem The individual will be living up to the ego ideal, which will result in positive feelings about self. The other options are incorrect; each represents a negative feeling.

Which belief by a nurse supports the highest degree of patient advocacy during a multidisciplinary patient care planning session?

Some symptoms of mental disorders reflect a person's cultural patterns. 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. All mental illnesses are not culturally determined. Schizophrenia and bipolar disorder are cross-cultural disorders, but this understanding has little relevance to patient advocacy. Symptoms of mental disorders change from culture to culture.

A psychiatric technician says, "Little of what takes place on the behavioral health unit seems to be theory based." A nurse educates the technician by identifying which common use of Sullivan's theory?

Structure of the therapeutic milieu of most behavioral health units The structure of the therapeutic environment has, as its foci, an accepting atmosphere and provision of opportunities for practicing interpersonal skills. Both constructs are directly attributable to Sullivan's theory of interpersonal relationships. Sullivan's interpersonal theory did not specifically consider the use of restraint or seclusion. Assessment based on the developmental level is more the result of Erikson's theories. Sequencing nursing actions based on the priority of patient needs is related to Maslow's hierarchy of needs.

A basic level registered nurse works with patients in a community setting. Which groups should this nurse expect to lead? Select all that apply

Symptom management Medication education Self-care Symptom management, medication education, and self-care groups represent psychoeducation, a service provided by the basic level registered nurse.

A person received an invitation to be in the wedding of a friend who lives across the country. The individual is afraid of flying. What type of therapy should the nurse recommend?

Systematic desensitization Systematic desensitization is a type of therapy aimed at extinguishing a specific behavior, such as the fear of flying. Psychoanalysis and short-term dynamic therapy are aimed at uncovering conflicts. Milieu therapy involves environmental factors.

Which research evidence would most influence a group of nurses to change their practice?

Systematic review of randomized controlled trials 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.

An experienced nurse says to a new graduate, "When you've practiced as long as I have, you'll instantly know how to take care of psychotic patients." What is the new graduate's best analysis of this comment? Select all that apply.

The experienced nurse may have lost sight of patients' individuality, which may compromise the integrity of practice. New research findings must be continually integrated into a nurse's practice to provide the most effective care. 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.

A 26-month-old child displays negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No!' when given direction. What do you think is wrong?" Select the nurse's best reply.

This is normal for your child's age. The child is striving for independence." These negative behaviors are typical of a child around the age of 2 years whose developmental task is to develop autonomy. The remaining options indicate the child's behavior is abnormal.

The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for depression. Which question best implements this assessment?

What are your worst and best times of day? Mood changes throughout the day are related to circadian rhythms. Questions about sleep pattern would also be relevant to circadian rhythms. The question about seeing or hearing things is relevant to the assessment for illusions and hallucinations. The question about thinking is relevant to the assessment of thought processes. The other question is relevant to assessment of memory.

A nurse must assess several new patients at a community mental health center. Conclusions concerning current functioning should be made on the basis of:

a continuum from mentally healthy to unhealthy. Because mental health and mental illness are relative concepts, assessment of functioning is made by using a continuum. Mental health is not based on conformity; some mentally healthy individuals do not conform to society's norms. Most individuals occasionally display illogical or irrational thinking. The rate of intellectual and emotional growth is not the most useful criterion to assess mental health or mental illness.

A patient is hospitalized for a reaction to a psychotropic medication and then is closely monitored for 24 hours. During a predischarge visit, the case manager learns the patient received a notice of eviction on the day of admission. The most appropriate intervention for the case manager is to:

arrange a temporary place for the patient to stay until new housing can be arranged. The case manager should intervene by arranging temporary shelter for the patient until suitable housing can be found. This is part of the coordination and delivery of services that falls under the case manager role. The other options are not viable alternatives.

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

connected with others. 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.

A nurse finds a new patient uncommunicative about recent life events. The nurse suspects marital and economic problems. The social worker's assessment is not available. The most effective action the nurse can take is to:

consult Axis IV of the DSM-IV-TR in the medical record. The physician's admission note identifies psychosocial and environmental problems on Axis IV pertinent to the patient's situation, providing another source of information for the nurse. Asking the patient who shares a room with him or her violates patient privacy rights. Persistent questioning may cause the patient to withdraw. Delaying the discussion until the social worker's assessment is available is not an effective solution.

A patient is admitted to the psychiatric hospital for assessment and evaluation. Which assessment finding best indicates that the patient has a mental illness? The patient:

describes mood as consistently sad, discouraged, and hopeless .A patient who reports having a consistently negative mood is describing a mood alteration. The incorrect options describe mentally healthy behaviors and common problems that do not indicate mental illness.

A patient's spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. The nurse should explain that SSRIs:

destroy increased amounts of neurotransmitters Depression is thought to be related to the lowered availability of the neurotransmitter serotonin. SSRIs act by blocking the reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. They actually prevent the destruction of serotonin, have no effect on acetylcholine and dopamine production, and do not block muscarinic or alpha1- norepinephrine receptors.

The spouse of a patient with schizophrenia asks, "Which neurotransmitters are more active when a person has schizophrenia?" The nurse should state, "The current thinking is that the thought disturbances are related to increased activity of: (Select all that apply.)

dopamine norepinephrine Dopamine plays a role in the integration of thoughts and emotions, and excess dopamine is implicated in the thought disturbances of schizophrenia. Increased activity of norepinephrine also occurs. Substance P is most related to the pain experience. Histamine decrease is associated with depression. Increased GABA is associated with anxiety reduction.

A drug causes muscarinic-receptor blockade. A nurse will assess the patient for:

dry mouth 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 alpha1-receptor antagonism.

A cognitive strategy a nurse could use to assist a very dependent patient would be to help the patient:

examine thoughts about being independent Cognitive theory suggests that one's thought processes are the basis of emotions and behavior. Changing faulty learning makes the development of new adaptive behaviors possible. Revealing dream content would be used in psychoanalytical therapy. Taking prescribed medications is an intervention associated with biological therapy. A dependent patient needs to develop independence.

The relapse of a patient with schizophrenia is related to medication noncompliance. The patient is hospitalized for 5 days, medication is restarted, and the patient's thoughts are now more organized. The patient's family members are upset and say, "It's too soon about the patient being scheduled for discharge. Hospitalization is needed for at least a month." The nurse should:

explain that the patient will continue to improve if medication is taken regularly. Patients no longer stay in the hospital until every vestige of a symptom disappears. The nurse must assume responsibility to advocate for the patient's right to the least restrictive setting as soon as the symptoms are under control and for the right of citizens to control health care costs. The health care provider will use the same rationale. Shifting blame will not change the discharge. Calling security is unnecessary. The nurse can handle this matter.

A student nurse prepares to administer oral medications to a patient with major depression, but the patient refuses the medication. The student nurse should:

explore the patient's concerns about the medication, and report to the staff nurse. The patient has the right to refuse medication in most cases. The patient's reason for refusing should be ascertained, and the refusal should be reported to a unit nurse. Sometimes refusals are based on unpleasant side effects that can be ameliorated. Threats and manipulation are inappropriate. Medication refusal should be reported to permit appropriate intervention.

A patient is hospitalized for major depression. Of the medications listed, a nurse can expect to provide the patient with teaching about:

fluoxetine (Prozac) Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), an antidepressant that blocks the reuptake of serotonin with few anticholinergic and sedating side effects; clozapine (Clozaril) is an antipsychotic medication; chlordiazepoxide (Librium) is an anxiolytic drug; and tacrine (Cognex) is used to treat Alzheimer disease.

A nurse can anticipate anticholinergic side effects will be likely when a patient is taking:

fluphenazine (Prolixin) Fluphenazine, a first-generation antipsychotic medication, exerts muscarinic blockade, 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.

A nurse psychotherapist works with an anxious, dependent patient. The therapeutic strategy most consistent with the framework of psychoanalytic psychotherapy is:

focusing on feelings developed by the patient toward the nurse Positive or negative feelings of the patient toward the nurse or therapist represent transference. Transference is a psychoanalytic concept that can be used to explore previously unresolved conflicts. Emphasizing medication compliance is more related to biological therapy. Identifying patient strengths and assets would be consistent with supportive psychotherapy. The use of psychoeducational materials is a common "homework" assignment used in cognitive therapy.

A single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away several weeks ago. The parent seeks the help of a therapist specializing in cognitive therapy. The psychotherapist who uses cognitive therapy will treat the patient by:

helping the patient identify faulty thinking Cognitive therapy emphasizes the importance of changing erroneous ways people think about themselves. Once faulty thinking changes, the individual's behavior changes. Focusing on unconscious mental processes is a psychoanalytic approach. Negatively reinforcing undesirable behaviors is behavior modification, and discussing ego states relates to transactional analysis.

The goal for a patient is to increase resiliency. Which outcome should a nurse add to the plan of care? Within 3 days, the patient will:

identify healthy coping behaviors in response to stressful events. The patient's ability to identify healthy coping behaviors indicates adaptive, healthy behavior and demonstrates an increased ability to recover from severe stress. Describing feelings associated with loss and stress does not move the patient toward adaptation. The remaining options are maladaptive behaviors.

A nurse uses Peplau's interpersonal therapy while working with an anxious, withdrawn patient. Interventions should focus on:

improving the patient's interactional skills The nurse-patient relationship is structured to provide a model for adaptive interpersonal relationships that can be generalized to others. Changing the patient's perceptions about his- or herself would be appropriate for cognitive therapy. Reinforcing specific behaviors would be used in behavioral therapy. Using medications would be the focus of biological therapy.

The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing

increased concentration of neurotransmitters in the synaptic gap If the reuptake of a substance is inhibited, then it accumulates in the synaptic gap and its concentration increases, permitting the ease of the transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with a normal rather than a depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

A nurse assesses an inpatient psychiatric unit, noting that exits are free from obstruction, no one is smoking, the janitor's closet is locked, and all sharp objects are being used under staff supervision. These observations relate to:

management of milieu safety Members of the nursing staff are responsible for all aspects of milieu management. The observations mentioned in this question directly relate to the safety of the unit. The other options, although part of the nurse's concerns, are unrelated to the observations cited.

An advanced practice nurse determines a group of patients would benefit from therapy in which peers and interdisciplinary staff all have a voice in determining the level of the patients' privileges. The nurse would arrange for:

milieu therapy Milieu therapy is based on the idea that all members of the environment contribute to the planning and functioning of the setting. The other therapies are all individual therapies that do not fit the description.

A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to:

mood improvement SSRIs affect mood, relieving depression in many patients. 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 patient hospitalized with a mood disorder has aggression, agitation, talkativeness, and irritability. A nurse begins the care plan based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n):

mood stabilizer The symptoms describe a manic attack. Mania is effectively treated by the antimanic drug lithium and selected anticonvulsants such as carbamazepine, valproic acid, and lamotrigine. No drugs from the other classifications listed are effective in the treatment of mania.

A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha1 receptors because the patient may experience:

orthostatic hypotension Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of alpha1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Patients should be taught ways of minimizing this phenomenon.

A nurse should assess a patient taking a medication with anticholinergic properties for inhibited function of the:

parasympathetic nervous system Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When acetylcholine action is inhibited by anticholinergic drugs, parasympathetic symptoms such as blurred vision, dry mouth, constipation, and urinary retention appear. The functions of the sympathetic nervous system, the reticular activating system, and the medulla oblongata are not affected by anticholinergic medications.

A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking:

phenelzine Patients taking phenelzine, an MAOI, must be on a tyramine-free diet to prevent hypertensive crisis.

Planning for patients with mental illness is facilitated by understanding that inpatient hospitalization is generally reserved for patients who:

present a clear danger to self or others. Hospitalization is justified when the patient is a danger to self or others, has dangerously decompensated, or needs intensive medical treatment. The incorrect options do not necessarily describe patients who require inpatient treatment.

On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to:

prevent destruction of acetylcholine. Increased acetylcholine plays a role in learning and memory. Preventing the destruction of acetylcholine by acetylcholinesterase results in higher levels of acetylcholine with the potential for improved memory. GABA is known to affect anxiety level rather than memory. Increased dopamine causes symptoms associated with schizophrenia or mania rather than improves memory. Decreasing dopamine at receptor sites is associated with Parkinson disease rather than improving memory.

A patient has taken many conventional antipsychotic drugs over years. The health care provider, who is concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics:

produce fewer motor side effects. Atypical antipsychotic drugs often exert their action on the limbic system rather than the basal ganglia. The limbic system is not involved in motor disturbances. Atypical antipsychotic medications are not more readily available. They are not considered to be of higher potency; rather, they have different modes of action. Atypical antipsychotic drugs tend to be more expensive.

A nurse uses Maslow's hierarchy of needs to plan care for a psychotic patient. Which problem will receive priority? The patient:

refuses to eat or bathe. The need for food and hygiene is physiological and therefore takes priority over psychological or meta-needs in care planning.

Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community with serious and persistent mental illness? Within 3 months, the patient will:

report a sense of well-being. 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.

The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 and a granulocyte count of 1500 mm 3. The nurse should:

report the laboratory results to the health care provider. 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. The drug should be withheld because the health care provider will discontinue it. The health care provider may repeat the laboratory test, but, in the meantime, the drug should be withheld. Giving aspirin and forcing fluids are measures that are less important than stopping the administration of the drug.

A 40-year-old adult living with parents states, "I'm happy but I don't socialize much. My work is routine. When new things come up, my boss explains them a few times to make sure I understand. At home, my parents make decisions for me, and I go along with them." A nurse should identify interventions to improve this patient's:

self-concept The patient feels the need for multiple explanations of new tasks at work and, despite being 40 years of age, allows both parents to make all decisions. These behaviors indicate a poorly developed self-concept.

The parent of a 4-year-old rewards and praises the child for helping a younger sibling, being polite, and using good manners. A nurse supports the use of praise because according to the Freudian theory, these qualities will likely be internalized and become part of the child's:

superego In the Freudian theory, the superego contains the "thou shalts" or moral standards internalized from interactions with significant others. Praise fosters internalization of desirable behaviors. The id is the center of basic instinctual drives, and the ego is the mediator. The ego is the problem-solving and reality-testing portion of the personality that negotiates solutions with the outside world. The preconscious is a level of awareness from which material can be easily retrieved with conscious effort.

Which patient statements identify qualities of nursing practice with high therapeutic value? (Select all that apply.) "The nurse:

talks in language I can understand." helps me keep track of my medications." looks at me as a whole person with different needs." 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.

The following patients are seen in the emergency department. The psychiatric unit has one bed available. Which patient should the admitting officer recommend for admission to the hospital? The patient who:

who is a single parent and hears voices saying, "Smother your infant." Admission to the hospital would be justified by the risk of patient danger to self or others. The other patients have issues that can be handled with less restrictive alternatives than hospitalization.

The spouse of a patient with schizophrenia says, "I don't understand why childhood experiences have anything to do with this disabling illness." Select the nurse's response that will best help the spouse understand this condition.

"Although this disorder more likely has a biological rather than psychological origin, the support and involvement of caregivers is very important." Many of the most prevalent and disabling mental disorders have been found to have strong biological influences. Helping the spouse understand the importance of his or her role as a caregiver is also important. Empathy is important but does not increase the spouse's level of knowledge about the cause of the patient's condition. Not all mental illnesses are the result of genetic factors. Psychologic stress is not at the root of most mental disorders.

A participant at a community education conference asks, "What is the most prevalent mental disorder in the United States?" Select the nurse's best response.

"Anxiety disorders" The prevalence for schizophrenia is 1.1% per year. The prevalence of all affective disorders (e.g., depression, dysthymia, bipolar) is 9.5%. The prevalence of anxiety disorders is 13.3%.

A nurse assesses a newly admitted patient with depression. Which statement is an example of "attending"?

"I'd like to sit with you a while so you may feel more comfortable talking with me." 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 nontherapeutic.

Which patient statement would lead a nurse to suspect that the developmental task of infancy was not successfully completed?

"I'm afraid to let anyone really get to know me." According to Erikson, the developmental task of infancy is the development of trust. The patient's statement that he or she is afraid of becoming acquainted with others clearly shows a lack of ability to trust other people. Having warm and close friendships suggests the developmental task of infancy was successfully completed. The third option suggests rigidity rather than mistrust. The fourth option suggests failure to resolve the crisis of Initiative versus Guilt.

A patient tells a nurse, "I have psychiatric problems and am in and out of hospitals all the time. Not one of my friends or relatives has these problems." Select the nurse's best response

"It sounds like you are concerned that others don't experience the same challenges as you." Mental illness affects many people at various times in their lives. No class, culture, or creed is immune to the challenges of mental illness. The correct response also demonstrates the use of reflection, a therapeutic communication technique. It is not true that mental illness affects 50% of the population in any given year. Asking patients if they blame themselves is an example of probing.

A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse's most caring comment

"Let's discuss some means of coping other than suicide when you have these feelings." 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.

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?

"My nurse spends time listening to me talk about my problems. That helps me feel like I'm not alone." 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 remaining options give examples of statements that demonstrate advocacy or giving advice.

A patient asks a nurse, "What are neurotransmitters? My doctor says mine are out of balance." The best reply would be:

"Neurotransmitters are chemicals that pass messages between brain cells." Stating that neurotransmitters are chemicals that pass messages between brain cells gives the most accurate information. Neurotransmitters are 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 incorrect responses do not answer the patient's question, are demeaning, and provide untrue and misleading information.

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?

"Our patients need our help to learn behaviors that will help them get along in society." 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

Which statements most clearly reflect the stigma of mental illness? Select all that apply.

"People claim mental illness so they can get disability checks." "If people with mental illness went to church, they would be fine." "Mental illness is a result of the breakdown of the American family." Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. Many mental illnesses are genetically transmitted. Neuroimaging can show changes associated with some mental illnesses.

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'll lose your skills." Select the best response by the student interested in psychiatric nursing.

"Psychiatric nurses use complex communication skills, as well as critical thinking, to solve multidimensional problems. I'm challenged by those situations." 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.

The parent of a child who has schizophrenia tearfully asks a nurse, "What could I have done differently to prevent this illness?" Select the nurse's most caring response.

"Schizophrenia is a biological illness with similarities to diabetes and heart disease. You are not to blame for your child's illness." Patients and families need reassurance that the major mental disorders are biological in origin and are not the "fault" of parents. Knowing the biological nature of the disorder relieves feelings of guilt over being responsible for the illness. The incorrect responses are neither wholly accurate nor reassuring; they fall short of being reassuring and place the burden of having faulty genes on the shoulders of the parents.

Cognitive therapy was provided for a patient who frequently said, "I'm stupid." Which statement by the patient indicates the therapy was effective?

"Sometimes I do stupid things." "I'm stupid" is an irrational thought. A more rational thought is, "Sometimes I do stupid things." The latter thinking promotes emotional self-control. The incorrect options reflect irrational thinking.

A critical care nurse asks a psychiatric nurse about the difference between a DSM-IV-TR diagnosis and a nursing diagnosis. Select the psychiatric nurse's best response.

"The DSM-IV-TR diagnosis influences the medical treatment; the nursing diagnosis offers a framework to identify interventions for problems a patient has or may experience." 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 the DSM-IV-TR and a nursing diagnosis consider culture. The DSM-IV-TR is multiaxial. Nursing diagnoses also consider potential problems.

A patient states, "I'm starting cognitive behavioral therapy. What can I expect from the sessions?" Which responses by the nurse are appropriate? Select all that apply.

"The therapist will be active and questioning." "You may be given homework assignments." "The goal is to increase your subjectivity about thoughts that govern your behavior." Cognitive therapists are active rather than passive during therapy sessions because they help patients to reality test their thinking. Homework assignments are given and completed outside the therapy sessions. Homework is usually discussed at the next therapy session. The goals of cognitive therapy are to assist the patient to identify inaccurate cognitions, to reality test their thinking, and to formulate new, accurate cognitions. Dream describing applies to psychoanalysis, not cognitive behavioral therapy. The desired outcome of cognitive therapy is to assist patients in increasing their objectivity, not subjectivity, about the cognitions that influence behavior.

A student nurse tells the instructor, "I don't need to interact with my patients. I learn what I need to know by observation." The instructor can best interpret the nursing implications of Sullivan's theory to the student by responding:

"nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." Sullivan believed that the nurse's role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan's theory. The nurse who does not interact with the patient cannot demonstrate these cornerstones. Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The third response pertains to Maslow's theory. The fourth response pertains to behavioral theory.

A newly admitted patient is profoundly depressed, mute, and motionless. The patient has refused to bathe and eat for a week. Which score would be expected on the patient's global assessment of functioning?

10 The patient is unable to maintain personal hygiene, oral intake, or verbal communication. The patient is dangerous to self because of the potential for starvation. A GAF score of 100 indicates high-level functioning. A score of 80 or 50 suggests higher functional abilities than the patient presently displays.

A multidisciplinary health care team meets 12 hours after an adolescent is hospitalized after a suicide attempt. Members of the team report their assessments. What outcome can be expected from this meeting?

A treatment plan will be determined. Treatment plans are formulated early in the course of treatment to streamline the treatment process and reduce costs. It is too early to determine the need for alternative postdischarge living arrangements. Neuroimaging is not indicated for this scenario.

A patient shows the nurse an article from the Internet about a healthproblem. Which characteristic of the web site's address most alerts the nurse that the site may have biased and prejudiced information?

Address ends in ".com." 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.