Mental health exam 2
8. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the past 24 hours. Which client symptom should the nurse immediately report to the ED physician? 1. Antecubital bruising 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 4. Dehydration
Answer: 2 This is correct. High blood pressure should immediately be reported to the physician. High blood pressure and other complications associated with alcohol withdrawal may progress to delirium tremens and seizures within 48 to 72 hours following cessation of prolonged alcohol consumption.
19. The nurse is providing counseling to clients diagnosed with MDD. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? 1. Psychoanalytic theory 2. Interpersonal theory 3. Cognitive theory 4. Behavioral theory
Answer: 3 This is correct. Beck and colleagues (1979) proposed a theory suggesting that the primary disturbance in depression is cognitive rather than affective. The underlying cause of the depression is cognitive distortions that result in negative thinking.
8. At which time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibit more pronounced symptoms? 1. When they first awaken 2. In the middle of the night 3. At twilight 4. After taking medications
Answer: 3 This is correct. Clients with Alzheimer's disease exhibit more-pronounced symptoms at twilight (late afternoon and evening), a phenomenon termed sundowning.
30. Students in a community health nursing class recently attended a lecture regarding tobacco use. Which student statement reflects the lecturer's teaching was effective? 1. "The percentage of adult men who smoke is higher than that of women and adolescents." 2. "Nicotine is the most widely used substance in the United States." 3. "Clients with severe mental illness have higher rates of smoking than those without mental illness." 4. "Smoking increases the risk of infant death due to inborn cardiac and respiratory defects."
Answer: 3 This is correct. Clients with severe mental illness and those in addiction treatment have higher rates of tobacco use compared with the general population. As many as 93% of people in addiction treatment and 40% percent of those with severe mental illness report using tobacco (Substance Abuse and Mental Health Services Administration, 2015).
5. A depressed client reports to the nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, which is the cause of this client's symptoms? 1. Depression is a result of anger turned inward. 2. Depression is a result of abandonment. 3. Depression is a result of repeated failures. 4. Depression is a result of negative thinking.
Answer: 3 This is correct. Learning theory describes Seligman's model (1973), which asserts a state of "learned helplessness" exists in humans who have experienced numerous failures and predisposes individuals to depression by imposing a feeling of lack of control over their life situations.
21. A 75-year-old client with a long history of depression is currently taking doxepin (Sinequan) 100 mg daily. The client also takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? 1. Risk for ineffective thermoregulation R/T anhidrosis 2. Risk for constipation R/T excessive fluid loss 3. Risk for injury R/T orthostatic hypotension 4. Risk for infection R/T suppressed white blood cell count
Answer: 3 This is correct. Orthostatic hypotension is a side effect of the tricyclic antidepressant doxepin (Sinequan), placing the client at risk for injury. Dehydration related to flu symptoms and a diuretic further increases the risk for orthostatic hypotension.
3. The nurse is planning care for a client diagnosed with bipolar disorder: manic episode. Which should be the first priority of the listed client outcomes? 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours per night
Answer: 3 This is correct. Safety of the client and others is the priority over physical and social needs.
28. The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? 1. By asking directly if the client has ever had a problem with alcohol 2. By using the Clinical Institute Withdrawal Assessment scale 3. By using a screening tool, such as the CAGE questionnaire 4. By referring the client for physician evaluation
Answer: 3 This is correct. The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.
9. Which of the following is considered a predisposing factor for depression? 1. Decreased serum cortisol levels 2. Decreased thyroid function 3. Decreased sodium levels 4. Genetic factors
Answer: 4 This is correct. Twin studies suggest a strong genetic factor in the etiology of affective illness, including depressive disorders and bipolar disorders.
17. The nurse is reviewing STAT laboratory data of a client presenting in the ED. What is the minimum blood alcohol concentration at which the nurse should expect intoxication to occur? 1. 50 mg/dL 2. 100 mg/dL 3. 250 mg/dL 4. 300 mg/dL
Answer: 2 This is correct. The minimum blood alcohol concentration at which intoxication occurs is 100 mg/dL. The range for intoxication is 100 to 200 mg/dL. Death has been reported at concentrations ranging from 400 to 700 mg/dL.
23. A client diagnosed with MDD was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention is most appropriate to help the client address spirituality as it relates to the illness? 1. Encourage the client to bring into awareness underlying sources of guilt. 2. Teach the client that religious beliefs should be put into perspective. 3. Confront the client with the irrational nature of the belief system. 4. Assist the client to modify his or her belief system to improve coping skills.
Answer: 1 This is correct. A client raised in an environment that reinforces one's inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to appraise distorted responsibility and dysfunctional guilt realistically.
21. Which nursing diagnosis is appropriate for a client who is unable to identify objects, confabulating, screaming, and demanding verbalizations? 1. Impaired verbal communication 2. Disturbed sensory perception 3. Situational low self-esteem; grieving 4. Disturbed thought processes; impaired memory
Answer: 1 This is correct. A client with a nursing diagnosis of impaired verbal communication would exhibit the following behaviors: the inability to name objects/people, loss of memory for words, difficulty finding the right word, confabulation, incoherent, screaming, and demanding verbalizations.
12. A client is admitted to the psychiatric unit with a diagnosis of MDD. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? 1. A simple, structured daily schedule with limited choices of activities 2. A daily schedule filled with activities to promote socialization 3. A flexible schedule that allows the client opportunities for decision-making 4. A schedule that includes mandatory activities to decrease social isolation
Answer: 1 This is correct. A simple, structured daily schedule with limited choices of activities is more appropriate.
15. A client diagnosed with an NCD due to Alzheimer's disease is disoriented, ataxic, and wanders. Which nursing diagnosis is the priority? 1. Disturbed thought processes 2. Self-care deficit 3. Risk for injury 4. Altered health-care maintenance
Answer: 3 This is correct. The priority nursing diagnosis is "risk for injury" related to the client's ataxia (muscular incoordination) and purposeless wandering. Safety is always a priority.
23. A client is asking the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the nurse's best reply? 1. "This medication will help you maintain your abstinence." 2. "This medication will cause uncomfortable symptoms if you consume alcohol." 3. "This medication will decrease the effect alcohol has on your body." 4. "This medication will lower your risk of experiencing a complicated withdrawal."
Answer: 1 This is correct. Acamprosate calcium (Campral) has been approved by the U.S. Food and Drug Administration for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.
12. The nurse expects a client experiencing prodromal symptoms of schizophrenia to demonstrate which of the following? 1. Significant deterioration in functioning 2. Poor relationships with peers 3. Disturbances in thought processing 4. Disorganized motor behavior
Answer: 1 This is correct. An individual begins to show signs of significant deterioration in premorbid functioning during the prodromal phase of schizophrenia.
26. ____________________ is the inability to perform motor activities despite intact motor function. 1. Apraxia 2. Aphasia 3. Dementia 4. Delirium
Answer: 1 This is correct. Apraxia is the inability to perform motor activities despite intact motor function.
6. A nursing instructor is teaching about donepezil. A student asks, "How does this work? Will this cure Alzheimer's disease?" Which reply by the instructor is appropriate? 1. "Donepezil delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 2. "Donepezil encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." 3. "Donepezil delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." 4. "Donepezil encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."
Answer: 1 This is correct. Donepezil slows the progression of Alzheimer's disease by inhibiting acetylcholinesterase, which delays the destruction of the neurotransmitter acetylcholine, which is necessary for memory processes.
3. A 16-year-old client diagnosed with schizophrenia is experiencing auditory command hallucinations. The client reports the voices are telling him to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the nurse's most appropriate reply? 1. "Auditory hallucinations are caused by increased dopamine levels in the brain." 2. "Hallucinations can be caused by medication interactions." 3. "Hallucinations occur when there is not enough serotonin in the brain." 4. "Auditory hallucinations are mainly due to abnormal hormonal changes."
Answer: 1 This is correct. Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Hallucinations are positive symptoms of schizophrenia related to increased production or release of dopamine at nerve terminals. Antipsychotic medications reduce psychotic symptoms by lowering brain levels of dopamine.
22. A client is admitted with a diagnosis of PDD. Which client statement describes a symptom consistent with this diagnosis? 1. "I have been sad most of the time for the past several years." 2. "I find myself preoccupied with death." 3. "Sometimes I hear voices telling me to kill myself." 4. "I'm afraid to leave the house."
Answer: 1 This is correct. PDD is characterized by depressed mood for most of the day for more days than not, for at least 2 years.
3. The nurse suspects the client of having MDD due to the client having psychomotor retardation. Which of the following would be an example of psychomotor retardation? 1. The client is disheveled and malodorous. 2. The client exhibits promiscuous behaviors. 3. The client ambulates independently. 4. The client has maxed-out charge cards.
Answer: 1 This is correct. Psychomotor retardation can manifest as being disheveled and malodorous.
18. The nurse is administering clozapine to a client diagnosed with schizophrenia. Which symptoms require the nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention
Answer: 1 This is correct. Sore throat, fever, and malaise are symptoms of infection related to agranulocytosis and require immediate nursing intervention. Agranulocytosis is a potentially life-threatening side effect of the atypical antipsychotic medication clozapine. It is characterized by a severe lack of white blood cells (leukopenia).
1. Which student statement indicates that learning has occurred regarding risk factors for the development of delirium in older adults? 1. "Taking multiple medications may lead to adverse interactions or toxicity." 2. "Age-related cognitive changes may lead to alterations in mental status." 3. "Lack of rigorous exercise may lead to decreased cerebral blood flow." 4. "Decreased social interaction may lead to profound isolation and psychosis."
Answer: 1 This is correct. Taking multiple medications may lead to adverse reactions or toxicity and put an older adult at risk for the development of delirium. Symptoms of delirium include difficulty sustaining and shifting attention, impaired memory, and confusion (disorientation to time and place).
4. Which of the following best defines secondary depression? 1. Depressive symptoms that occur as a consequence of an adverse side effect of certain medications. 2. Depressive symptoms as a result of MDD exacerbation and elevated serotonin levels. 3. Depressive symptoms that occur as a result of psychomotor retardation. 4. Depressive symptoms that occur with abrupt discontinuation of antidepressants.
Answer: 1 This is correct. The DSM-5 stipulates that medical conditions should be identified before a psychiatric diagnosis is made, as symptoms of a medical condition may mimic those of psychiatric disorders. Depressive symptoms that occur as a consequence of a non-mood disorder or as an adverse effect of certain medications are known as secondary depression. Secondary depression may be related to medication side effects, neurological disorders, electrolyte or hormonal disturbances, nutritional deficiencies, and other physiological or psychological conditions.
19. A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why the nurse should encourage the client to try nonpharmacological interventions first? 1. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. 2. Sedative-hypnotics are expensive and have numerous side effects. 3. Sedative-hypnotics interfere with necessary rapid eye movement sleep. 4. Sedative-hypnotics are not as effective as antidepressant medications for promoting sleep.
Answer: 1 This is correct. The client has a known substance use disorder. In addition to the possibility of psychological and physiological addiction, as well as tolerance, sedative-hypnotics cause CNS depression. These physiological depressive effects are additive when combined with each other, are often unpredictable, and can be fatal.
7. The nurse is assessing a new client diagnosed with schizophrenia. The client states "Those people behind the desk won't stop laughing at me." The nurse determines the client is experiencing which symptom? 1. Ideas of reference 2. Loose associations 3. Delusion of influence 4. Tangentiality
Answer: 1 This is correct. The client is experiencing ideas of reference, which are characterized by an individual's belief that a neutral event within the environment has a special and personal meaning.
18. A client has a history of daily bourbon drinking for the past 6 months. He is brought to an ED by family, who reports that his last drink was 1 hour ago. It is now midnight. When will the nurse expect this client to exhibit withdrawal symptoms? 1. Between 3 a.m. and 11 a.m. 2. Shortly after a 24-hour period 3. At the beginning of the third day 4. Withdrawal is individualized and cannot be predicted
Answer: 1 This is correct. The client will begin to exhibit alcohol withdrawal between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or a reduction in heavy and prolonged alcohol use.
7. A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to AA is most appropriate for the nurse to discuss with the client during discharge teaching? 1. After discharge, the client will attend 90 AA meetings in 90 days. 2. After discharge, the client will rely on an AA sponsor to control alcohol cravings. 3. After discharge, the client will incorporate family members in AA attendance. 4. After discharge, the client will seek appropriate deterrent medications through AA.
Answer: 1 This is correct. The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. AA accepts alcoholism as an illness and promotes total abstinence as the only cure.
26. The psychiatric-mental health nurse is evaluating the care of a client recovering from an episode of psychosis. Which is the most appropriate long-term goal for the client? 1. Define and test reality. 2. Participate in social activities. 3. Maintain appropriate eye contact. 4. Verbalize feelings of anxiety.
Answer: 1 This is correct. The most appropriate long-term goal for a client recovering from a psychotic episode is to be able to define and test reality, reducing or eliminating the occurrence of hallucinations.
9. A client diagnosed with NCD has progressive memory loss, diminished cognitive functioning, verbal aggression, and is experiencing frustration. Which nursing intervention is most appropriate? 1. Schedule structured daily routines. 2. Minimize environmental lighting. 3. Organize a group activity to present reality. 4. Explain the consequences for aggressive behaviors.
Answer: 1 This is correct. The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and verbal aggression.
20. A client who has been diagnosed with bipolar I disorder states, "God has taught me how to decode the Bible." The nurse should anticipate which combination of medications would be ordered to address this client's symptoms? 1. Lithium carbonate (Lithobid) and risperidone (Risperdal) 2. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) 3. Valproic acid (Depakote) and sertraline (Zoloft) 4. Valproic acid (Depakote) and lamotrigine (Lamictal)
Answer: 1 This is correct. The nurse should anticipate lithium carbonate (Lithobid) and risperidone (Risperdal) to be ordered. Lithium carbonate is a mood stabilizer, and risperidone is an atypical antipsychotic. Risperidone will address the client's symptoms of psychosis (delusions of grandeur) and has sedative effects to reduce symptoms of agitation, hyperactivity, and/or insomnia. Lithium takes 1 to 3 weeks to take its full effect.
11. A psychiatrist prescribes an MAOI for a client. Which foods should the nurse teach the client to avoid? 1. Pepperoni pizza and red wine 2. Bagels with cream cheese and tea 3. Apple pie and coffee 4. Potato chips and diet cola
Answer: 1 This is correct. The nurse should instruct the client to avoid pepperoni pizza and red wine. Clients taking MAOIs should not eat foods containing tyramine. Examples of foods high in tyramine are aged cheese, red wine, beer, chocolate, and smoked and processed meats. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread. This combination of pizza ingredients (including pepperoni) and red wine has the highest level of tyramine of the foods listed.
24. A client diagnosed with bipolar disorder states, "I hate oatmeal. Let's get everybody together to do exercises. I'm thirsty and I'm burning up. Get out of my way; I have to see that guy." Which is the priority nursing action? 1. Assess the client's vital signs. 2. Offer to have the dietitian discuss food preferences. 3. Encourage the client to lead the exercise program in the community meeting. 4. Acknowledge the client briefly, and then walk away.
Answer: 1 This is correct. The nurse should obtain vital signs to assess the client's physical status. The client's statement of "I'm thirsty and I'm burning up" may indicate that the client is dehydrated or has an infection or another physical illness. Symptoms of mania may mask a comorbid physical illness. Assessment is the first step of the nursing process.
9. A client diagnosed with brief psychotic disorder states, "The voices keep telling me I must kill the president." Which is the priority nursing diagnosis? 1. Disturbed sensory perception 2. Disturbed thought processes 3. Risk for violence: other directed 4. Impaired verbal communication
Answer: 3 This is correct. The priority nursing diagnosis is "risk for violence: other directed." The client is having auditory hallucinations commanding the client to kill the president. Others are at risk for harm should the client act on the commands. Safety is always the priority.
13. A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention should be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate parenteral nutrition (PN) to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.
Answer: 1 This is correct. The nurse should provide the client with high-protein, high-calorie, nutritious finger foods and drinks that can be consumed "on the run" throughout the day. Because of the client's hyperactive state, the client has difficulty sitting still long enough to eat a meal.
28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention is most therapeutic for this client? 1. Use a calm, unemotional approach during client interactions. 2. Focus primarily on enforcing limits. 3. Limit interactions to decrease external stimuli. 4. Encourage the client to establish social relationships with peers.
Answer: 1 This is correct. The nurse's most therapeutic action is to maintain a calm, unemotional approach during client interactions. Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another.
15. The nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, "You can't do this to me. Do you know who I am?" Which is the priority nursing action in this situation? 1. To provide self and client with a safe environment 2. To redirect the client to the needed assessment information 3. To provide high-calorie finger foods to meet nutritional needs 4. To reorient the client to person, place, time, and situation
Answer: 1 This is correct. The priority nursing action is to protect the client and staff from injury. Clients experiencing mania demonstrate excessive psychomotor activity, low frustration tolerance, and impulsivity, which can lead to aggressive behavior. Hallucinations and delusions are common in acute mania.
1. Which is the priority nursing diagnosis for a client experiencing alcohol withdrawal? 1. Risk for injury related to (R/T) central nervous system (CNS) stimulation 2. Disturbed thought processes R/T tactile hallucinations 3. Ineffective coping R/T powerlessness over alcohol use 4. Ineffective denial R/T continued alcohol use despite negative consequences
Answer: 1 This is correct. The priority nursing diagnosis for a client experiencing alcohol withdrawal is "Risk for injury R/T CNS." Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia. Safety is always a priority.
4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. Which should be the priority nursing diagnosis for this client? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment
Answer: 1 This is correct. The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses based on physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.
5. A lonely, depressed, divorced person has been self-medicating with cocaine for the past year. Which term should the nurse use to best describe the client's situation? 1. Psychological addiction 2. Physical addiction 3. Substance addiction 4. Social addiction
Answer: 1 This is correct. The term psychological addiction best describes the client's situation. A client is psychologically addicted to a substance when there is an overwhelming desire to use a substance to produce pleasure or avoid discomfort.
10. Which condition appears to have a connection to bipolar disorder in youth? 1. Attention deficit-hyperactivity disorder (ADHD) 2. Disruptive mood dysregulation disorder 3. Nonepisodic irritability 4. Schizophrenia
Answer: 1 This is correct. There appears to be a connection between ADHD and bipolar disorder in youth.
13. Which statement indicates to the nurse that a client is experiencing a delusion? 1. "Spies are watching everything I do." 2. "There is a worm on the back of the television." 3. "Bugs are crawling all over me." 4. "I really don't feel like going to group today."
Answer: 1 This is correct. This statement indicates the client is experiencing a delusion. Delusions are fixed, false beliefs that are irrational and that the individual maintains are true despite evidence to the contrary.
21. A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? 1. Gross tremors, delirium, hyperactivity, and hypertension 2. Disorientation, peripheral neuropathy, and hypotension 3. Oculogyric crisis, amnesia, ataxia, and hypertension 4. Hallucinations, fine tremors, confabulation, and orthostatic hypotension
Answer: 1 This is correct. Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms of alcohol withdrawal can occur within 4 to 12 hours of cessation of or a reduction in heavy and prolonged alcohol use. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.
33. Which of the following explanations should the nurse include when teaching parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. 1. Symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18 years. 5. Genetic predisposition is not a reliable diagnostic determinant.
Answer: 1, 2 1: This is correct. It is difficult to diagnose children and adolescents because symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. 2: This is correct. It is difficult to diagnose children and adolescents, as children are naturally active, energetic, and spontaneous.
32. Which of the following instructions regarding lithium therapy should be included in the nurse's discharge teaching? Select all that apply. 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2500 to 3000 mL of fluid per day. 4. Restrict potassium-containing foods. 5. Take medication on an empty stomach.
Answer: 1, 2, 3 1: This is correct. The client taking lithium should avoid excessive use of caffeine. 2: This is correct. The client taking lithium should maintain a consistent sodium intake. 3: This is correct. The client taking lithium should consume at least 2,500 to 3,000 mL of fluid per day.
32. A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to the nurse that discharge teaching about this medication has been successful? Select all that apply. 1. "I'll have to let my surgeon know about this medication before surgery." 2. "Guess I will have to give up my glass of red wine with dinner." 3. "I'll have to be very careful about reading food and medication labels." 4. "I'm going to limit my water intake." 5. "I'll be sure not to stop this medication abruptly."
Answer: 1, 2, 3, 5 1: This is correct. Clients should inform other prescribers that they are taking an MAOI. 2: This is correct. To avoid a hypertensive emergency, clients taking MAOIs, such as phenelzine (Nardil), should not use alcohol or ingest foods high in tyramine. Examples of foods high in tyramine are aged cheese, wine (especially Chianti), beer, chocolate, colas, coffee, tea, and smoked and processed meats. 3: This is correct. The client will need to be diligent with reading food and medication labels to avoid tyramine and notify other prescribers of their MAOI use. 5: This is correct. MAOIs should not be stopped abruptly.
34. A client and a nurse therapist are developing a treatment plan that includes strategies to manage bipolar disorder. Which should be included? Select all that apply. 1. Maintain a consistent sleep schedule. 2. Become an expert on the disorder. 3. Create a daily medication schedule. 4. Set a time frame to achieve remission. 5. Develop an emergency plan.
Answer: 1, 2, 3, 5 1: This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to manage lifestyle factors, such as sleep time. 2: This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to become an expert on the disorder. 3: This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to take medications regularly. 5: This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to develop a plan for emergencies.
31. The parent of a 20-year-old client recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia? Select all that apply. 1. Prostaglandins 2. Glutamate 3. Thyroxine 4. Dopamine 5. Erythropoietin
Answer: 1, 2, 4 1: This is correct. Increased numbers of dopamine receptors, the neurotransmitter glutamate, and abnormalities in neuroregulators such as prostaglandins and endorphins have been implicated in the etiology of schizophrenia. 2: This is correct. Increased numbers of dopamine receptors, the neurotransmitter glutamate, and abnormalities in neuroregulators such as prostaglandins and endorphins have been implicated in the etiology of schizophrenia. 4: This is correct. Increased numbers of dopamine receptors, the neurotransmitter glutamate, and abnormalities in neuroregulators such as prostaglandins and endorphins have been implicated in the etiology of schizophrenia.
23. Which nursing interventions would be used for a client with a nursing diagnosis of risk of trauma related to impairments in cognitive and psychomotor functioning? Select all that apply. 1. Store frequently used items within easy access. 2. Keep cigarettes and lighters out of reach of the client. 3. Keep the side rails up when the client is in bed. 4. Keep a dim light on at night.
Answer: 1, 2, 4 1: This is correct. Items should be placed within easy reach. 2: This is correct. Lighters and cigarettes should be kept out of the client's reach to prevent injury. 4: This is correct. A dim light should be kept on at night to avoid tripping should the client get up at night.
35. The clinic nurse is reviewing the medication list of a client diagnosed with medication-induced bipolar disorder. The nurse recognizes which may have precipitated the client's mood disturbance? Select all that apply. 1. Oral contraceptives 2. Antihypertensives 3. Dopamine agonists 4. Corticosteroids 5. Alpha-adrenergics
Answer: 1, 2, 4 1: This is correct. Oral contraceptives have been known to evoke mood symptoms. 2: This is correct. Antihypertensives have been known to evoke mood symptoms. 4: This is correct. Corticosteroids have been known to evoke mood symptoms.
33. The nurse understands psychotic postpartum depression is characterized by which symptoms? Select all that apply. 1. Agitation 2. Fear the infant will be harmed 3. Loss of libido 4. Guilt 5. Sleep disturbances
Answer: 1, 2, 4 1: This is correct. Postpartum depression with psychotic features is characterized by depressed mood, agitation, indecision, and an abnormal attitude toward bodily functions. The symptoms can be severe and incapacitating. 2: This is correct. The symptoms can be severe and incapacitating. There may be lack of interest in or rejection of the baby or a morbid fear that the baby may be harmed, accompanied by delusions and hallucinations. 4: This is correct. Postpartum depression with psychotic features is characterized by guilt. The symptoms can be severe and incapacitating.
16. A client is diagnosed with cyclothymic disorder. Which client behaviors should the nurse expect to find on assessment? 1. The client expresses "feeling blue most of the time." 2. The client has endured periods of elation and dysphoria for more than 2 years. 3. The client continually fixates on hopelessness and thoughts of suicide. 4. The client has labile moods with periods of acute mania.
Answer: 2 This is correct. The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder.
32. Which of the following nursing statements exemplifies important insights to promote effective intervention with clients diagnosed with substance use disorders? Select all that apply. 1. "I am easily manipulated and need to work on this prior to caring for these clients." 2. "Because of my parent's alcoholism, I need to examine my attitude toward these clients." 3. "Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights." 4. "Opioid addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training." 5. "I can fix clients diagnosed with substance use disorders as long as I truly care about them."
Answer: 1, 2, 4 1: This is correct. The nurse must examine their feelings about working with clients diagnosed with substance use disorders. The role alcohol or other substances have played (or play) in the life of the nurse will affect the way in which they interact with a client who has a substance use disorder. The nurse who recognizes being easily manipulated will be able to examine their feelings and abilities to work with substance abuse clients. 2: This is correct. The nurse must examine their feelings about working with clients diagnosed with substance use disorders. The role alcohol or other substances have played (or play) in the life of the nurse will affect the way in which they interact with a client who has a substance use disorder. 4: This is correct. The nurse must examine their feelings about working with clients diagnosed with substance use disorders. Unless nurses fully understand and accept their own attitudes and feelings, they cannot be empathetic toward clients' problems. Nurses must be able to separate the client from the behavior and accept the client with unconditional positive regard.
27. When planning care for clients diagnosed with schizophrenia, which of the following should the nurse recognize as an integral part of a rehabilitative program? Select all that apply. 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training
Answer: 1, 2, 4, 5 1: This is correct. Group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Effective treatment requires a comprehensive, multidisciplinary effort. 2: This is correct. Group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Medication management enables the client to control symptoms and participate in other therapeutic modalities. 4: This is correct. Group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Family support is essential for coping skills, problem-solving, and ability to meet the client's needs. 5: This is correct. Group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Social skills training enables the client to interact with others appropriately.
33. Which of the following student statements about the complications of hepatic encephalopathy indicate further student teaching is needed? Select all that apply. 1. "A diet rich in protein will promote hepatic healing." 2. "This condition causes a rise serum ammonia, leading to impaired mental functioning." 3. "In this condition, blood accumulates in the abdominal cavity." 4. "Neomycin and lactulose are used in the treatment of this condition." 5. "This condition is caused by the inability of the liver to convert ammonia to urea."
Answer: 1, 3 1: This is correct. Treatment of hepatic encephalopathy requires temporary elimination of protein from the diet. 3: This is correct. Treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia by means of neomycin or lactulose. Ascites is a condition in which an excessive amount of serous fluid accumulates in the abdominal cavity in response to portal hypertension.
30. A 20-year-old female has a diagnosis of PMDD. Which of the following should the nurse identify as consistent with this diagnosis? Select all that apply. 1. Symptoms are causing significant interference with daily activities. 2. Client-rated mood is 2/10 for the past 6 months. 3. Mood swings occur the week before onset of menses. 4. Client reports subjective difficulty concentrating. 5. Client manifests pressured speech when communicating.
Answer: 1, 3, 4 1: This is correct. One of the essential features of PMDD is decreased interest in activities during the week prior to menses. 3: This is correct. Two of the essential features of PMDD are markedly depressed mood and mood swings during the week prior to menses, improving shortly after the onset of menstruation and becoming minimal or absent in the week after menses. 4: This is correct. One of the essential features of PMDD is markedly depressed mood, such as decreased concentration, during the week prior to menses and improving shortly after the onset of menstruation.
4. The nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurse's best reply? 1. "Tell him to stop talking about the voices." 2. "Ask him what the voices are saying to him." 3. "Tell him you know the voices are real to him." 4. "Encourage him not to worry about the voices."
Answer: 2 This is correct. Safety is always the nurse's priority. The parents should ask what the voices are saying to identify whether the child is hearing commands to harm self or others. The nurse should encourage the parents to acknowledge the voices are real to the child, but let the child know they do not share the perception. Use of the word "voices" helps avoid reinforcing the hallucination.
25. A client in stage 3 Alzheimer's disease frequently wanders. Which interventions can the nurse implement to reduce the incidence of wandering and promote safety? Select all that apply. 1. Keep the client on a strict toileting schedule. 2. Allow the client a large, unrestricted area to wander. 3. Walk with the individual and redirect them back to the unit. 4. Ensure the exits are not electronically controlled. 5. Keep the client on a structured schedule of activities.
Answer: 1, 3, 5 1: This is correct. A client may wander because they need to go to the restroom and are lost. Keeping them on a strict toileting schedule may prevent wandering. 3: This is correct. The nurse should walk with the client and then redirect them back to the unit. 5: This is correct. The nurse should keep the client on a structured schedule of activities to keep the client busy and prevent boredom.
34. The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? Select all that apply. 1. "Are you thinking about hurting yourself or someone else?" 2. "Can you tell me your feelings about dying?" 3. "Where do you keep your gun?" 4. "Have you told your psychiatrist you feel like dying?" 5. "Have you thought about how you would hurt yourself?"
Answer: 1, 3, 5 1: This is correct. Ask the client directly, "Are you thinking about hurting yourself or someone else?" The risk of suicide is greatly increased if the client has developed a plan and has strong intentions, especially if means exist for the client to execute the plan. 3: This is correct. Asking the client where they may have weapons or a means to harm themself is an appropriate question. This may increase the likelihood of the client carrying out a plan of self-harm. 5: This is correct. Ask the client directly, "Have you thought about how you would hurt yourself?" The risk of suicide is greatly increased if the client has developed a plan and has strong intentions, especially if means exist for the client to execute the plan.
28. The nurse is administering risperidone to a client diagnosed with schizophrenia. The nurse anticipates the mediation to have a therapeutic effect on which symptoms? Select all that apply. 1. Somatic delusions 2. Social isolation 3. Gustatory hallucinations 4. Flat affect 5. Clang associations
Answer: 1, 3, 5 1: This is correct. Atypical antipsychotics, such as risperidone, have been shown to be effective in the treatment and prevention of the positive symptoms of schizophrenia. Somatic delusions, gustatory hallucinations, and clang associations are some of the positive symptoms of schizophrenia. 3: This is correct. Atypical antipsychotics, such as risperidone, have been shown to be effective in the treatment and prevention of the positive symptoms of schizophrenia, including gustatory hallucinations. 5: This is correct. Atypical antipsychotics, such as risperidone, have been shown to be effective in the treatment of the positive symptoms of schizophrenia, such as clang associations.
34. Which are associated with codependent behaviors among nurses? Select all that apply. 1. Overspending 2. Social isolation 3. Perfectionism 4. Personal identity 5. Denial
Answer: 1, 3, 5 1: This is correct. Excessive spending is a compulsive behavior that may accompany codependency. 3: This is correct. Perfectionism can be a behavior that accompanies codependent behaviors. 5: This is correct. Denial is a common behavior that accompanies codependent behaviors.
22. On which teaching topics would the nurse focus for a caregiver of a client with stage 5 Alzheimer's disease? Select all that apply. 1. How to assist with some ADLs, such as hygiene, dressing, and grooming 2. How to care for decubitus ulcers resulting from immobility 3. How to apply medications to compromised skin resulting from bowel and bladder incontinence 4. Tools to help reorientate the client to time and place
Answer: 1, 4 1: This is correct. With moderate cognitive decline in stage 5 Alzheimer's disease, individuals lose the ability to perform some ADLs independently, such as hygiene, dressing, and grooming, and require some assistance to manage these on an ongoing basis. 4: This is correct. In Stage 5, clients may become disoriented about place and time, but they maintain knowledge about themselves.
15. The nurse is administering medications to a client experiencing acute psychosis. The client's medication orders include haloperidol 50 mg PO bid; benztropine 1 mg PO daily, and zolpidem 10 mg PO at bedtime daily. The nurse administers benztropine to address which of the following? 1. Tactile hallucinations 2. Involuntary facial movements 3. Psychomotor retardation 4. Pacing back and forth
Answer: 2 This is correct. Benztropine is an anticholinergic medication used for symptoms of tardive dyskinesia, characterized by abnormal involuntary movements. Tardive dyskinesia is a potentially irreversible adverse effect of antipsychotic medications.
8. A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates learning has occurred? 1. "This disorder is more prevalent in lower socioeconomic groups." 2. "This disorder is more prevalent in higher socioeconomic groups." 3. "This disorder is equally prevalent in all socioeconomic groups." 4. "This disorder is unpredictable based on socioeconomic groups."
Answer: 2 This is correct. Bipolar disorder is more prevalent in higher socioeconomic groups.
27. The psychiatric-mental health nurse is creating a plan of care for a child diagnosed with a depressive disorder. The parents report the child does not seem to know how to make friends and does not seem to be doing as well in school as a family member who is in the same grade. Recently, their child started picking fights while waiting for the bus. The nurse recognizes that the child's depressive symptoms occur among which age group? 1. 3 to 5 years 2. 6 to 8 years 3. 9 to 12 years 4. 11 to 14 years
Answer: 2 This is correct. Children ages 6 to 8 years may express vague physical complaints and display aggressive behavior. They often cling to parents, avoid new people and challenges, and lag behind their classmates in social skills and academic competence. MDD in children and adolescents can be identified using criteria similar to those used for adults. It is not uncommon, however, for the symptoms of depression to be manifested differently during different ages in childhood.
25. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to find on assessment? 1. Pacing 2. Flight of ideas 3. Lability of mood 4. Irritability
Answer: 2 This is correct. Clients diagnosed with bipolar disorder: manic episode experience fragmented cognition and perception, often accompanied by psychosis. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speech and abrupt changes from topic to topic.
2. The nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance use disorder? 1. Narcotic pain medication is contraindicated for all clients with active substance use problems. 2. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction. 4. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.
Answer: 2 This is correct. Cross-tolerance occurs when one drug lessens an individual's response to another drug. Clients who are regularly using alcohol or benzodiazepines have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
21. The nurse is admitting a client to the inpatient psychiatric unit. Which intervention is most appropriate to reduce the client's delusional thinking? 1. Provide evidence to orient the client to reality. 2. Explore the client's feelings about the delusions. 3. Use logical explanations to address the delusions. 4. Encourage the client to provide reasons for the delusions.
Answer: 2 This is correct. Delusions are fixed false beliefs that are irrational that an individual maintains are true despite evidence to the contrary. The individual continues to have the beliefs despite obvious proof that they are false or irrational. The nurse should focus on the client's feelings.
14. A client who is diagnosed with MDD asks the nurse what causes depression. Which is the nurse's most accurate response? 1. "Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine." 2. "The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role." 3. "Depression is a learned state of helplessness caused by ineffective parenting." 4. "Depression is caused by intrapersonal conflict between the id and the ego."
Answer: 2 This is correct. Depression is likely an illness that has varied and multiple causative factors; but at present, the exact cause of depressive disorders is not entirely understood.
27. A client's spouse asks, "What evidence supports the possibility of genetic transmission of bipolar disorder?" Which is the best nursing reply? 1. "Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors." 2. "Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder." 3. "Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress." 4. "More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds."
Answer: 2 This is correct. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great.
13. An isolative client was admitted 4 days ago with a diagnosis of MDD. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? 1. "We'll go to the dayroom when you are ready for group." 2. "I'll walk with you to the dayroom. Group is about to start." 3. "It must be difficult for you to attend group when you feel so bad." 4. "Let me tell you about the benefits of attending this group."
Answer: 2 This is correct. In the most acute stage of severe depression, clients may exhibit little to no motivation and have extreme difficulty making decisions; therefore, this function must be temporarily assumed by the staff. The nurse should use active communication to encourage the client to participate in therapy.
6. What is the priority reason for the nurse to perform a full physical health assessment on a client admitted with a diagnosis of MDD? 1. The attention during the assessment is beneficial in decreasing social isolation. 2. Depression is a symptom of several medical conditions. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed clients avoid addressing physical health and ignore medical problems.
Answer: 2 This is correct. It is a priority to identify and treat medical conditions because depressive symptoms may occur as a consequence of a nonmood disorder related to medication side effects, neurological disorders, electrolyte or hormonal disturbances, nutritional deficiencies, and other physiological or psychological conditions.
25. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with MDD. Which behavioral symptoms should the nurse expect to assess? 1. Anxiety and unconscious anger 2. Lack of attention to grooming and hygiene 3. Guilt and indecisiveness 4. Low self-esteem
Answer: 2 This is correct. Lack of attention to grooming and hygiene is a behavioral symptom of MDD.
16. The nurse assesses a client who exhibits a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement indicates the nurse understands the characteristics of positive and negative symptoms of schizophrenia? 1. Paranoia, anhedonia, and anergia are positive symptoms. 2. Paranoia, neologisms, and echolalia are positive symptoms. 3. Paranoia, anergia, and echolalia are negative symptoms. 4. Paranoia, flat affect, and anhedonia are negative symptoms.
Answer: 2 This is correct. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. Positive symptoms are present in a person with schizophrenia and would not be present in a person without the illness.
18. A newly admitted client is diagnosed with MDD with suicidal ideations. Which is the priority nursing intervention for this client? 1. Teach about the effect of suicide on family dynamics. 2. Carefully observe at varied intervals. 3. Encourage the client to spend a portion of each day interacting within the milieu. 4. Set realistic achievable goals to increase self-esteem and increase energy.
Answer: 2 This is correct. Risk for suicide is the priority concern for a client with MDD. The nurse should frequently assess for the presence and lethality risk of suicidal ideation. The intensity of suicide ideation can change over the course of hours or days.
1. A client exhibits paranoia, bizarre behaviors, neologisms, and delusions of persecution. While eating breakfast in the dayroom, the client starts yelling at others. Which is the nurse's first action? 1. Ensure client is swallowing each dose of medication. 2. Ask other clients to step out of the dayroom. 3. Call the provider for an order to place the client in restraints. 4. Escort the client to a less-stimulating environment.
Answer: 2 This is correct. Safety is always the nurse's priority. The nurse should move the other clients away from the client to protect them from harm.
17. The nurse is implementing a one-on-one suicide observation level with a client diagnosed with MDD. The client states, "I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? 1. "I really appreciate your concern, but I have been ordered to continue to watch you." 2. "Because we are concerned about your safety, we will continue to observe you." 3. "I am glad you are feeling better. The treatment team will consider your request." 4. "I will forward your request to your psychiatrist because it is his decision."
Answer: 2 This is correct. Suicidal clients often resist frequent observation and monitoring because it impedes the implementation of a suicide plan. The nurse should continually observe a client who is at risk for suicide.
29. The triage nurse notes a client with a history of alcohol use disorder has an elevated heart rate, palpitations, shortness of breath, and a dry cough. Which best explains the client's symptoms? 1. Alcoholic myopathy 2. Alcoholic cardiomyopathy 3. Esophagitis 4. Portal hypertension
Answer: 2 This is correct. Symptoms of alcoholic cardiomyopathy include decreased exercise tolerance, tachycardia, dyspnea, edema, palpitations, and nonproductive cough.
17. A client was admitted to the hospital after being treated in the emergency department for seizures following a head trauma. Within a few minutes of arriving on the floor, the admitting nurse noticed that the client had a difficult time sustaining attention and did not know where she was. Which statement describes the rationale for the abnormal behavior? 1. The client likely has a systemic illness. 2. The client is experiencing delirium. 3. The client is experiencing a metabolic imbalance from dehydration. 4. The client likely has a major NCD.
Answer: 2 This is correct. Symptoms of delirium usually begin quite abruptly (e.g., following a head injury or seizure). The duration of delirium is usually brief (e.g., 1 week; rarely more than 1 month). Upon elimination of the underlying causes, symptoms usually diminish over a 3- to 7-day period, but in some instances may take as long as 2 weeks. The age of the client and duration of the delirium influence the rate of symptom resolution.
24. The nurse is obtaining the mental health history of a client diagnosed with schizophrenia. The client's family reports that the client is hearing voices and cannot stay focused on the topic of a discussion. The nurse recognizes the client is demonstrating which symptom? 1. Delusions of reference 2. Tangentiality 3. Neologism 4. Loose associations
Answer: 2 This is correct. Tangentiality refers to a veering away from the topic of discussion and demonstrates difficulty in maintaining focus and attention.
30. Which carries a warning label stating that the use of the medication increases risk for suicidal thoughts and behaviors? 1. Antipsychotics 2. Antiepileptics 3. Mood stabilizers 4. Anxiolytics
Answer: 2 This is correct. The U.S. Food and Drug Administration requires that all antiepileptic (anticonvulsant) drugs carry a warning label indicating that use of the drugs increases risk for suicidal thoughts and behaviors. Clients treated with these medications should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior.
12. A parent who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement indicates to the nurse that the client has a positive prognosis? 1. "I'm not going to use heroin ever again. I know I can do it this time." 2. "I cannot control my use of heroin. It's stronger than I am." 3. "I'm going to get all my children back. They need their parent." 4. "Once I deal with my childhood physical abuse, recovery should be easy."
Answer: 2 This is correct. The client is accepting that the use of substances causes problems in significant life areas and that she is not able to prevent substance use. The client works to gain self-control and abstain from substances. The first step in the 12-step model for treatment is to admit powerlessness over the substance.
13. A client with a history of cerebrovascular accident is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client's assessment data, which diagnosis would the nurse expect the physician to assign? 1. Medication-induced delirium 2. VNCD 3. Altered thought processes 4. Alzheimer's disease
Answer: 2 This is correct. The client would most likely be diagnosed with VNCD. VNCD has an abrupt onset and a fluctuating pattern of progression. Cognitive impairment can occur with multiple small infarcts (sometimes called silent strokes) over time or with a single cerebrovascular event in a specific area of the brain.
18. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms? 1. 1.3 meq/L 2. 1.7 meq/L 3. 2.3 meq/L 4. 3.7 meq/L
Answer: 2 This is correct. The client's symptoms are correlated with a lithium level of 1.7 meq/L. The therapeutic level of lithium carbonate is 1.0 to 1.5 meq/L for acute mania and 0.6 to 1.2 meq/L for maintenance therapy. Symptoms of lithium toxicity include persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, and mental confusion. Lithium toxicity can lead to renal failure and death.
6. A client diagnosed with schizophrenia tells the nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is the correct charting entry to describe this client's statement? 1. "The client is speaking with clang associations." 2. "The client is expressing feelings with a neologism." 3. "The client demonstrates paranoid thinking." 4. "The client is communicating with a word salad."
Answer: 2 This is correct. The client's use of the word "Shopatouliens" is an example of a neologism, a newly invented word that is meaningless to others but has symbolic meaning to the individual.
2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the past 3 nights and a 12-lb weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit related to (R/T) bipolar disorder as evidenced by (AEB) concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
Answer: 2 This is correct. The client's weight loss indicates that the body's metabolic needs have not been met. The nurse should prioritize interventions to ensure proper nutrition and health. The assessment data does not indicate that the client is at risk for self-harm.
26. A newly admitted client diagnosed with MDD states, "I have never considered suicide." Later, the client confides to the nurse about plans to "end it all" by medication overdose. Which is the most helpful nursing reply? 1. "There is nothing to worry about. We will handle it together." 2. "Bringing this up is a very positive action on your part." 3. "We need to talk about the things you have to live for." 4. "I think you should consider all of your options prior to taking this action."
Answer: 2 This is correct. The most helpful reply is to convey an attitude of unconditional acceptance of the client by acknowledging sharing of a suicide plan was a positive action. The nurse will also encourage the client to participate actively in establishing a safety plan.
10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks the nurse, "I heard about something called monoamine oxidase inhibitors (MAOIs). Can't my doctor add that to my medications?" Which is the most appropriate nursing reply? 1. "This combination of drugs can lead to delirium tremens." 2. "A combination of an MAOI and fluvoxamine can lead to a life-threatening hypertensive crisis." 3. "That's a good idea. There have been good results with the combination of these two drugs." 4. "The only disadvantage would be the exorbitant cost of the MAOI."
Answer: 2 This is correct. The nurse should explain that combining an MAOI and fluvoxamine can lead to a life-threatening hypertensive crisis. Fluvoxamine is an SSRI antidepressant. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.
29. As clients are leaving the dayroom following a group therapy session, the nurse notices that a client admitted for acute mania is clenching and unclenching both fists, swearing, and glaring at a staff member. Which action should the nurse take first? 1. Calmly ask the client to go to the "quiet room." 2. Instruct clients to return to the dayroom. 3. Prepare to administer a sedative medication. 4. Ask a staff member to call hospital security.
Answer: 2 This is correct. The nurse should intervene at the first sign of increased anxiety, agitation, or verbal or behavioral aggression and should remove others from the environment to ensure client and others' safety.
2. A client is diagnosed with major depressive disorder (MDD). Which nursing diagnosis should the nurse assign to the client to address a behavioral symptom of this disorder? 1. Altered communication related to (R/T) feelings of worthlessness as evidenced by (AEB) anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered thought processes R/T hopelessness AEB persecutory delusions 4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
Answer: 2 This is correct. The nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of MDD. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.
25. Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? 1. Darken the room to reduce stimuli to prevent seizures. 2. Assess aggressive behaviors to prevent injury to self or others. 3. Administer lorazepam (Ativan) to reduce the rebound effects on the CNS. 4. Teach the negative effects of alcohol on the body.
Answer: 2 This is correct. The nursing priority is to prevent injury to the client or others. Aggressiveness is one of the symptoms associated with alcohol intoxication. Other symptoms include, but are not limited to, impaired judgment, impaired attention, and irritability.
20. The nurse is caring for a college student who started hearing voices, has not attended classes for the past 4 weeks, was yelling accusations at others, and has stopped communicating with family and friends. Which is the nurse's priority nursing diagnosis? 1. Altered thought processes related to (R/T) hearing voices as evidenced by (AEB) increased anxiety 2. Risk for other-directed violence R/T yelling accusations 3. Social isolation R/T paranoia AEB absence from classes 4. Risk for self-directed violence R/T depressed mood
Answer: 2 This is correct. The priority nursing diagnosis is "risk for other-directed violence R/T yelling accusations." Safety is always the priority. Verbal aggression is a behavior indicating risk for violence. Other risk factors include aggressive body language, command hallucinations, rage reactions, and destruction of objects in the environment.
21. The nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement provides supportive evidence of this symptom? 1. "I can't stop my sexual urges. They have led me to numerous affairs." 2. "I'm the world's most perceptive attorney." 3. "My spouse is distraught about my overspending." 4. "The Federal Bureau of Investigation (FBI) is out to get me."
Answer: 2 This is correct. The statement "I'm the world's most perceptive attorney" indicates the client is experiencing delusions of grandeur. Hallucinations and delusions (usually paranoid and grandiose) are common symptoms during acute mania. Grandiosity is defined as an unrealistic sense of superiority (a sustained view of oneself as better than others).
22. Which client statement indicates to the nurse that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? 1. "I will limit my intake of fluids daily." 2. "I will maintain normal salt intake." 3. "I will take Lithobid on an empty stomach." 4. "I will increase my caloric intake to prevent weight loss."
Answer: 2 This is correct. The statement indicates that the client understands there is no need to restrict sodium intake while taking Lithobid.
17. After teaching a client about lithium carbonate (Lithane), the nurse would conclude teaching was successful based on which client statement? term-141 1. "I should expect to feel better in a couple of days." 2. "I'll call my doctor immediately if I experience any diarrhea or ringing in my ears." 3. "If I forget a dose, I can double the dose the next time I take this drug." 4. "I need to restrict my intake of any food containing salt."
Answer: 2 This is correct. This statement indicates that the nurse's teaching was effective. Signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.
5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)
Answer: 2 This is correct. Valproic acid (Depakote) is an anticonvulsant. For many years, the drug of choice for treatment and management of bipolar mania was lithium carbonate; however, in recent years, anticonvulsant drugs have been found to have mood-stabilizing effects, either alone or in combination with lithium.
27. When assessing a client with polysubstance abuse, the nurse recognizes that withdrawal from which substance may require a life-saving emergency intervention? 1. Dextroamphetamine (Dexedrine) 2. Diazepam (Valium) 3. Morphine (Astramorph) 4. Phencyclidine (PCP)
Answer: 2 This is correct. Withdrawal from the CNS depressant diazepam (Valium) would require life-saving emergency intervention. When used at high does for prolonged periods, withdrawal symptoms include autonomic hyperexcitability, tachycardia, hallucinations, illusions, psychomotor agitation, seizures, respiratory depression, and death.
31. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should the nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. 1. Gender differences in social opportunities that occur with age 2. Drastic temperature and barometric pressure changes 3. Increased levels of melatonin 4. Variations in serotonergic functioning 5. Inaccessibility of resources for dealing with life stressors
Answer: 2, 3, 4 2: This is correct. Drastic temperature and barometric pressure changes are contributing factors to the etiology of the client's symptoms. 3: This is correct. An increase in melatonin levels is a contributing factor to the etiology of the client's symptoms. 4: This is correct. Variations in serotonergic functioning are contributing to the etiology of the client's symptoms. Several studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).
35. Which of the following are symptoms of inhalant intoxication? Select all that apply. 1. Bradycardia 2. Euphoria 3. Hyperactive reflexes 4. Ataxia 5. Nystagmus
Answer: 2, 4, 5 2: This is correct. Euphoria is a symptom of inhalant intoxication, as are dizziness, ataxia, disinhibition, nystagmus, blurred vision, hypoactive reflexes, and generalized muscle weakness. 4: This is correct. Ataxia is a symptom of inhalant intoxication, as are dizziness, euphoria, disinhibition, nystagmus, blurred vision, hypoactive reflexes, and generalized muscle weakness. 5: This is correct. Nystagmus is a symptom of inhalant intoxication, as are dizziness, ataxia, euphoria, disinhibition, blurred vision, hypoactive reflexes, and generalized muscle weakness.
24. The nurse is caring for an older adult client with an NCD who becomes agitated. Which intervention by the nurse is appropriate? Select all that apply. 1. Demand the client attend a group activity session. 2. Administer an antipsychotic medication as prescribed. 3. Restrain the client immediately. 4. Encourage doll therapy. 5. Attempt to reason with the client. 6. Perform relaxation techniques.
Answer: 2, 4, 6 2: This is correct. Antipsychotics can help reduce agitation. 4: This is correct. According to the literature, doll therapy has been shown to improve mood and reduce agitation. 6: This is correct. Performing relaxation techniques can help reduce agitation.
30. The nursing instructor asks a nursing student to describe concepts of the Recovery Model. Which concepts should the nursing student include? Select all that apply. 1. Employs positive and negative reinforcement 2. Uses personal values to determine meaning in life 3. Focuses on interactions within a social environment 4. Centers on improving adherence to prescribed medications 5. Allows client primary control over care decisions
Answer: 2, 5 2: This is correct. The Recovery Model highlights the dimension of active engagement. The client identifies goals based on personal values or what they define as giving meaning and purpose to life. 5: This is correct. The Recovery Model highlights the dimension of active engagement and empowerment of the client in decision making. The client identifies goals based on personal values or what he or she defines as giving meaning and purpose to life.
8. The nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a Mini-Mental Status Examination? 1. To rule out bipolar disorder 2. To rule out schizophrenia 3. To rule out a neurocognitive disorder (NCD) 4. To rule out a personality disorder
Answer: 3 This is correct. A Mini-Mental Status Examination should be performed to rule out an NCD. Memory loss, confused thinking, or apathy may actually be the result of depression. This is often referred to as pseudodementia.
14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? 1. The client will accomplish activities of daily living (ADLs) independently by discharge. 2. The client will verbalize feelings during group sessions by discharge. 3. The client will remain safe from harm throughout hospitalization. 4. The client will use problem-solving to cope adequately after discharge.
Answer: 3 This is correct. A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase, the client is hyperactive and can inadvertently injure self or others. In the depressive phase, the client is at risk for self-harm.
18. A client diagnosed with Lewy body dementia has been prescribed an antipsychotic medication to manage a decline in mental capacities. Why would the nurse question this prescription? 1. Antipsychotic medications can cause Lewy body dementia to become a permanent condition. 2. Lewy body dementia does not affect cognitive functioning. 3. Clients with Lewy body dementia are highly sensitive to the extrapyramidal effects of antipsychotic medications. 4. Lewy body dementia causes an increase in acetylcholinesterase concentrations, which makes antipsychotic medications contraindicated.
Answer: 3 This is correct. Acetylcholinesterase concentrations are reduced in the brains of people with Lewy body dementia; as such, cholinesterase inhibitors are likely to be more effective for this population than for those with Alzheimer's dementia. These clients are highly sensitive to the extrapyramidal effects of antipsychotic medications.
23. A newly admitted client exhibits symptoms of paranoia and hallucinations. The client's spouse states, "I don't understand. My spouse hasn't hallucinated since the doctor prescribed thioridazine 2 years ago." The nurse recognizes which as the most likely explanation for the recurrence of the client's symptoms? 1. The client has developed tolerance to the medication. 2. The client has been taking the medication with food. 3. The client has not been taking the medication as prescribed. 4. The client has been drinking alcohol with the medication.
Answer: 3 This is correct. Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. An individual's lack of awareness of having an illness or disorder is the most common predictor of nonadherence to treatment and a poorer course of illness.
29. Which is associated with premenstrual dysphoric disorder (PMDD)? 1. Norepinephrine 2. Serotonin 3. Progesterone 4. Acetylcholine
Answer: 3 This is correct. An imbalance of the hormones estrogen and progesterone has been implicated in the predisposition to PMDD.
12. A client diagnosed with an NCD is exhibiting behavioral problems every day. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action would the nurse implement first? 1. Consult the psychologist regarding behavior-modification techniques. 2. Medicate the client with prn antianxiety medications. 3. Assess environmental triggers and potential unmet needs. 4. Anticipate the behavior, and restrain when pacing begins.
Answer: 3 This is correct. Assessment is the first step of the nursing process. Due to the cognitive decline experienced by a client diagnosed with an NCD, the nurse should first assess environmental triggers and potential unmet needs. The client's communication skills may be limited, and the client may become disoriented and frustrated.
10. After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of a major NCD due to Alzheimer's disease. Which statement would cause the nurse to question this diagnosis? 1. NCDs do not typically occur in African American clients. 2. The symptoms presented are more indicative of parkinsonism. 3. NCD does not develop suddenly. 4. There has been no triiodothyronine or thyroxine level evaluation ordered.
Answer: 3 This is correct. NCDs do not develop suddenly. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed. The disease is generally progressive and debilitating
13. A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "I just need to work harder to get him there on time." Which is the appropriate nursing response? 1. "Why do you assume responsibility for his behaviors?" 2. "Codependency is a typical behavior of spouses of alcoholics." 3. "Your husband needs to deal with the consequences of his drinking." 4. "Do you understand what the term enabler means?"
Answer: 3 This is correct. The appropriate nursing response is to use confrontation with caring. In stage I (the survival stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that their personal capabilities are unlimited.
20. A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? 1. Ineffective coping R/T unresolved anxiety and medication tolerance as evidenced by (AEB) substance abuse 2. Anxiety R/T poor sleep AEB difficulty falling asleep 3. Disturbed sleep pattern R/T chlordiazepoxide (Librium) tolerance AEB difficulty falling asleep 4. Risk for injury R/T addiction to chlordiazepoxide (Librium)
Answer: 3 This is correct. The client has developed a tolerance to chlordiazepoxide (Librium). Tolerance is defined as the need for increasingly larger or more frequent doses of a substance to obtain the desired effects originally produced by a lower dose.
22. A recovering alcoholic relapses and drinks a glass of wine. The client presents in the ED experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse recognizes that the client's symptoms indicate which of the following? 1. Alcohol poisoning 2. Cerebrovascular accident (CVA) 3. A reaction to disulfiram (Antabuse) 4. A reaction to tannins in the red wine
Answer: 3 This is correct. The client has most likely ingested alcohol while taking disulfiram (Antabuse), a drug that is administered as a deterrent to drinking. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a significant amount of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.
5. A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition? 1. Mania 2. Delirium 3. NCD 4. Parkinsonism
Answer: 3 This is correct. The client is exhibiting signs of an NCD, which is characterized by impairment in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate.
14. The nurse observes that a client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication does the nurse anticipate the provider will prescribe? 1. Benztropine 2. Clonazepam 3. Risperidone 4. Sertraline
Answer: 3 This is correct. The client is experiencing a hallucination. The nurse should expect the provider to order an antipsychotic medication. Risperidone is an atypical (newer-generation) antipsychotic used to reduce positive symptoms of schizophrenia.
15. During group therapy, a client diagnosed with alcohol use disorder states, "I would not have boozed it up if my spouse hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should the nurse interpret this statement? 1. The client is using denial by avoiding responsibility. 2. The client is using displacement by blaming his spouse. 3. The client is using rationalization to excuse his alcohol dependence. 4. The client is using reaction formation by appealing to the group for sympathy.
Answer: 3 This is correct. The client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior. This prolongs the client's denial that problems secondary to substance use exist.
26. A client diagnosed with alcohol use disorder joins a community 12-step program and states, "My life is unmanageable." Which of the following indicates the nurse's interpretation of the client's statement? 1. The client is using minimization as an ego defense. 2. The client is ready to sign an AA contract for sobriety. 3. The client has accomplished the first of 12 steps advocated by AA. 4. The client has met the requirements to be designated as an AA sponsor.
Answer: 3 This is correct. The first step of the AA program is, "We admitted we were powerless over alcohol—that our lives have become unmanageable."
25. A client diagnosed with psychosis asks the nurse to make the voices stop talking so he can go to sleep. Which is the most important nursing intervention? 1. Ask the client whether the voices seem familiar. 2. Guide the client to bed and gently rub their back. 3. Ask the client what the voices are saying. 4. Suggest the client tell the voices to go away.
Answer: 3 This is correct. The most important intervention is to assess the content of the hallucinations to prevent aggressive responses to command hallucinations (e.g., voices telling the client to hurt or kill themself). Ask the client "Are you hearing other voices? Are you able to distinguish those voices from my voice?"
22. A client states, "The voices keep saying I am evil." Which outcome criteria is most important to include in the client's plan of care? 1. Demonstrates the ability to perceive the environment correctly 2. Uses appropriate verbal communication when interacting with others 3. Identifies factors that increase anxiety and illicit hallucinations 4. Demonstrates the ability to relate satisfactorily to others
Answer: 3 This is correct. The most important outcome is that the client can identify factors that increase anxiety and trigger hallucinations. Symptoms of psychosis may be minimized or prevented if the patient can learn techniques to interrupt escalating anxiety.
8. A client diagnosed with schizophrenia says, "Can't you hear him? The devil keeps telling me I'm going to hell!" Which is the nurse's most appropriate reply? 1. "Did you take your medication this morning?" 2. "You are a good person, and you are not going to hell." 3. "It must be scary to hear that, but I don't hear a voice." 4. "The devil only talks to people who are receptive to his influence."
Answer: 3 This is correct. The nurse is communicating empathy and acceptance and is reassuring the client while not reinforcing the hallucination.
15. Which client information does the nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? 1. The client's understanding of the need for regular blood work 2. The client's mood and affect score, according to the facility's mood scale 3. The client's cognitive ability to understand information about the medication 4. The client's access to a support network willing to participate in treatment
Answer: 3 This is correct. The nurse must assess the client's cognitive ability to understand information about the medication. Phenelzine (Nardil) is an MAOI. To avoid a hypertensive emergency, clients taking MAOIs should not ingest foods high in tyramine, take certain medications, or use alcohol.
17. The nurse is providing discharge teaching to an elderly client diagnosed with schizophrenia. The client's medications include an antipsychotic (risperidone) and a beta-adrenergic blocking agent (propranolol). Which statement indicates the nurse understands the combined side effects of these medications? 1. "Concentrate on taking slow, deep, cleansing breaths." 2. "Limit your intake of foods that are high in sugar." 3. "Move slowly when you change from a lying down or sitting position." 4. "Always wear sunscreen and a hat when you are exposed to the sun."
Answer: 3 This is correct. The nurse should instruct the client to rise slowly when changing positions. The combination of antipsychotic medications and beta blockers can lead to orthostatic hypotension, placing the client at risk for injury.
2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should the nurse teach the client? 1. Side effects of medications 2. Deep breathing techniques 3. Ways to make eye contact when communicating 4. Techniques to improve memory and attention
Answer: 3 This is correct. The nurse should teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and maintain connectedness with others.
23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. Which should be the nurse's initial intervention? 1. Ask the group to take a vote on alternative weekend events. 2. Remind the client to quiet down or leave the dayroom. 3. Assist the client to move to a calmer location. 4. Discuss impulse control problems with the client.
Answer: 3 This is correct. The nurse's initial action should be to move the client to a calmer environment, as overstimulation can exacerbate symptoms of acute mania. The client's agitation and extreme hyperactivity place the client and others at risk for injury. The nurse's priority is always safety.
4. Which nursing intervention would take priority for a client in the late stage of Alzheimer's disease? 1. Improve cognitive status by encouraging involvement in social activities. 2. Decrease social isolation by providing group therapies. 3. Promote dignity by providing comfort, safety, and self-care measures. 4. Facilitate communication by providing assistive devices.
Answer: 3 This is correct. The nursing priority is to promote dignity. During the late stage, the person becomes bedbound and may have very active hands and repetitive movements, grunting, or other vocalizations. Speech and language are severely impaired, and the person may no longer recognize any family members. Caregivers need to complete most ADLs.
11. Upon admission for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." Assessment reveals blood pressure of 170/100 mm Hg, pulse of 110 bpm, respirations of 28 breaths/min, and a temperature of 97°F with dry skin, dry mucous membranes, and poor skin turgor. Which of the following is the priority nursing diagnosis? 1. Knowledge deficit 2. Denial 3. Deficient fluid volume 4. Ineffective individual coping
Answer: 3 This is correct. The priority nursing diagnosis is deficient fluid volume. A decrease in fluid volume during alcohol withdrawal can be due to a lack of intake as well as symptoms of nausea and vomiting. The client's data supports deficient fluid volume with the dry skin, dry mucous membranes, poor skin turgor, and elevated blood pressure and heart rate.
19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? 1. Ineffective individual coping R/T hospitalization AEB alcohol abuse 2. Altered nutrition: less than body requirements R/T mania AEB weight loss 3. Risk for violence: directed toward others R/T agitation and hyperactivity 4. Sleep pattern disturbance R/T flight of ideas AEB sleeping 1 to 2 hours per night
Answer: 3 This is correct. The priority nursing diagnosis is risk for violence: self-directed or other directed. Clients experiencing mania demonstrate excessive psychomotor activity, low frustration tolerance, and impulsivity, which can lead to aggressive behavior. Hallucinations and delusions are common in acute mania.
3. On the first day of a client's alcohol detoxification, which nursing intervention is the priority? 1. Encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage per protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
Answer: 3 This is correct. The priority nursing intervention is to administer chlordiazepoxide (Librium) per protocol. The benzodiazepine chlordiazepoxide (Librium) is often used for substitution therapy in alcohol withdrawal. Substitution therapy is used to reduce life-threatening effects of the rebound stimulation of the CNS that occurs during alcohol withdrawal.
11. An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal) 400 mg three times a day for mood stabilization. Which statement about this medication order is true? 1. "This dosage is within the recommended dosage range." 2. "This dosage is lower than the recommended dosage range." 3. "This dosage is more than twice the recommended dosage range." 4. "This dosage is four times higher than the recommended dosage range."
Answer: 3 This is correct. The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients 100-200 mg per day; 400 mg three times daily is well above the recommended dose.
20. The nurse notices that Martha, the primary caregiver for her spouse with Alzheimer's disease, seems distracted, and she asks how Martha is doing. "I'm doing OK," said Martha. "I'm just so overwhelmed. I can't seem to get anything done. Just when I think I'm handling everything, something else comes up. Hopefully things will settle down soon, and I can get a break." Which intervention would most help Martha cope with the caregiver strain she's expressing? 1. Teaching about symptoms of Alzheimer's disease 2. Information about the management of Alzheimer's disease 3. Referrals to support services for Alzheimer's disease 4. Recommending an Alzheimer's-friendly residence facility
Answer: 3 This is correct. There are several support services available for caregivers of clients with Alzheimer's disease. These include financial assistance, legal assistance, caregiver support groups, respite care, and home health care. All of these support services would help Martha deal with the caregiver strain she is experiencing.
7. Which nursing student statement requires further teaching regarding care for the client with NCD experiencing hallucinations? 1. "I will assess for side effects of medications that could cause hallucinations." 2. "My client wears a hearing aid. I need to ensure it is working properly." 3. "If I am not experiencing the hallucination, then it is likely the client is not either." 4. "I took the mirror off the wall because the client was seeing a false image."
Answer: 3 This is correct. This statement requires further teaching. Just because the student cannot see or hear what the client sees or hears does not mean it is not real to the client.
7. A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 lb in this time frame. Which is the appropriate nursing reply? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common but troubling side effect." 4. "Weight gain occurs only during the first month of treatment with this drug."
Answer: 3 This is correct. Weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.
31. The psychiatric-mental health nurse is providing discharge teaching for a client diagnosed with bipolar disorder. Which statement indicates that the nurse's teaching is effective? 1. "I shouldn't take my lithium when I have the flu." 2. "I am looking forward to having real coffee in the morning." 3. "I can get off medication in 5 years if I am stable." 4. "I'll be the designated driver since I shouldn't have alcohol with lamotrigine."
Answer: 4 This is correct. Clients taking lamotrigine (Lamictal), an antiepileptic mood stabilizer, should avoid consuming alcoholic beverages.
9. Which client statement demonstrates positive progress toward recovery from a substance use disorder? 1. "I have completed detox and therefore am in control of my drug use." 2. "I will attend Narcotics Anonymous (NA) meetings when I can't control my cravings." 3. "As a church deacon, my focus will now be on spiritual renewal." 4. "Taking those pills got out of control. It cost me my job, marriage, and children."
Answer: 4 This is correct. During the working phase of the relationship, the client accepts the fact that substance use causes problems. A client who takes responsibility for the consequences of substance use is making positive progress toward recovery.
7. The nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Fluoxetine (Prozac)
Answer: 4 This is correct. Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is an SSRI used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.
2. A client diagnosed with vascular dementia is discharged to home under the care of his spouse. Which information causes the nurse to question the client's safety? 1. His spouse works from home in telecommunication. 2. The client has worked the night shift his entire career. 3. His spouse has minimal family support. 4. The client smokes one pack of cigarettes per day.
Answer: 4 This is correct. Forgetfulness is an early symptom of vascular neurocognitive disorder (VNCD), and the client is at risk for burns related to forgotten smoking materials. VNCD is directly related to an interruption of blood flow to the brain. Symptoms result from death of nerve cells in regions nourished by diseased vessels. Hypertension is one of the most significant factors in the etiology.
20. Which client statement expresses typical underlying feelings of clients diagnosed with MDD? 1. "It's just a matter of time, and I will be well." 2. "If I ignore these feelings, they will go away." 3. "I can fight these feelings and overcome this disorder." 4. "Nothing will help me feel better."
Answer: 4 This is correct. Hopelessness and helplessness are typical affective symptoms of clients diagnosed with MDD.
24. The nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? 1. "Only oral ingestion of alcohol will cause a reaction when taking this drug." 2. "It is safe to drink beverages that have only 12% alcohol content." 3. "This medication will decrease your cravings for alcohol." 4. "Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug."
Answer: 4 This is correct. If disulfiram (Antabuse) is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.
26. The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom decor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? 1. Rooms should contain extra-large windows with views of the street. 2. Rooms should contain brightly colored walls with printed drapes. 3. Rooms should be painted deep colors and located close to the nurse's station. 4. Rooms should be painted with neutral colors and contain pale-colored accessories.
Answer: 4 This is correct. Neutral colors and pale accessories are most appropriate for a client experiencing mania. Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying, making it necessary to maintain low levels of stimuli in the client's environment (low lighting, few people, simple decor, low noise levels). Anxiety levels rise in a stimulating environment.
6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing reply? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa ensures a good night's sleep." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."
Answer: 4 This is correct. Olanzapine (Zyprexa) is an atypical antipsychotic used in acute manic episodes to reduce hyperactivity until the lithium carbonate (Eskalith) takes effect. Lithium carbonate may take 1 to 3 weeks to reach a therapeutic level and decrease hyperactivity.
31. A nurse in the ED assesses a 17-year-old client exhibiting symptoms of opioid intoxication. Which should be the nurse's first action? 1. Contact the parents. 2. Administer oxygen. 3. Open the crash cart. 4. Administer naloxone (Narcan).
Answer: 4 This is correct. Opioid intoxication is treated with narcotic antagonists, such as naloxone (Narcan), naltrexone (ReVia), or nalmefene (Revex), to reduce the potential for respiratory depression and death.
19. The nurse is reviewing the provider's orders for a client experiencing acute psychosis. The client's family tells the nurse the client has allergies to penicillin, prochlorperazine, and bee stings. Which medication order should the nurse question? 1. Haloperidol 5 mg intramuscularly every 4 hours as needed 2. Clozapine 150 mg PO twice daily 3. Risperidone 2 mg PO twice daily 4. Thioridazine 100 mg PO three times daily
Answer: 4 This is correct. Prochlorperazine and thioridazine are both classified as phenothiazines. They are contraindicated because there is cross-sensitivity among phenothiazines.
28. Electroconvulsive therapy (ECT) is considered the treatment of choice for which client? 1. A 39-year-old man experiencing recurrent suicidal ideation 2. A 23-year-old woman experiencing postpartum depression 3. A 41-year-old woman describing a suicide plan 4. A 67-year-old man explaining a recent suicide attempt
Answer: 4 This is correct. Research has identified ECT as generally safe for acute treatment of late-life depression and may be considered the treatment of choice for the elderly individual who is at acute suicidal risk or unable to tolerate antidepressant medications.
6. Which term should the nurse use to describe the administration of a CNS depressant during alcohol withdrawal? 1. Antagonist therapy 2. Deterrent therapy 3. Codependency therapy 4. Substitution therapy
Answer: 4 This is correct. Substitution therapy may be required to reduce the life-threatening effects of intoxication or withdrawal from some substances. Benzodiazepines are the most widely used group of drugs for substitution therapy in alcohol withdrawal.
1. A client is diagnosed with persistent depressive disorder (PDD) (dysthymia). Which should the nurse classify as an affective symptom of this disorder? 1. Social isolation with a focus on self 2. Low energy level 3. Difficulty concentrating 4. Gloomy and pessimistic outlook on life
Answer: 4 This is correct. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. A gloomy and pessimistic outlook on life is an affective symptom of dysthymia. Affective symptoms are those that relate to the mood.
19. A 36-year-old is admitted to the emergency department at 2:20 a.m. with a severe laceration to her forehead and incoherent speech. Paramedics report that they picked up the client at a local bar, and the bartender onsite said, "She seemed just fine when she came in. She must have had a lot to drink before she came here." Witness reports onsite confirmed that the woman fell off a bar stool and hit her head on the bar rail. Based on the information provided, a blood alcohol test was administered, and her blood alcohol content was 0.01%. The client's weight was recorded at 145 lbs. Incoherent speech is most likely attributed to which of the following? 1. Alcohol intoxication 2. Intoxication and fatigue due to the late hour 3. A primary NCD 4. A secondary NCD
Answer: 4 This is correct. The blood alcohol content of 0.01% and reports of the client's behavior prior to the fall indicate a likelihood of cerebral trauma associated with the fall.
4. Which client statement indicates a knowledge deficit related to substance use? 1. "Although it's legal, alcohol is one of the most widely abused drugs in our society." 2. "Tolerance to heroin develops quickly." 3. "Flashbacks from lysergic acid diethylamide (LSD) use may reoccur suddenly." 4. "Everyone smokes marijuana. It's harmless."
Answer: 4 This is correct. The client has a knowledge deficit related to substances, indicated by stating that smoking marijuana is harmless. Marijuana is known to have serious effects on the cardiovascular and respiratory systems.
16. Which action would the nurse take to promote safety in the client with an NCD? 1. Keep the client in the room furthest from the nurse's station. 2. Provide the client with glass items instead of disposable items. 3. Keep the bed in high position. 4. Encourage the client to call for assistance when getting out of bed.
Answer: 4 This is correct. The client should be instructed to call the nurse for assistance when getting out of bed.
9. A client diagnosed with bipolar disorder has taken lithium carbonate (Lithane) for 1 year; this client presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. The nurse should interpret these symptoms to be indicative of which of the following? 1. Consumption of foods high in tyramine 2. Common side effects of lithium carbonate 3. Lithium carbonate tolerance 4. Lithium carbonate toxicity
Answer: 4 This is correct. The client's symptoms indicate lithium carbonate toxicity. Symptoms of lithium carbonate toxicity include persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, and/or mental confusion. These symptoms require a physician to be notified.
10. The nurse notices a client is becoming very agitated. Which nursing intervention is most appropriate? 1. Instruct the client to watch television in the dayroom. 2. Maintain continuous eye contact when talking to the client. 3. Hold the client's hand while walking in the hallway. 4. Provide the client with adequate personal space.
Answer: 4 This is correct. The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and the client's risk for violence.
12. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients have difficulty sleeping." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."
Answer: 4 This is correct. The most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications.
16. The nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which initial outcome should the nurse expect the client to accomplish? 1. The client will identify one person to turn to for support. 2. The client will give up all old drinking buddies. 3. The client will be able to verbalize the effects of alcohol on the body. 4. The client will correlate life problems with alcohol use.
Answer: 4 This is correct. The nurse expects the client will correlate life problems with alcohol use. Acknowledging the association between personal problems and use of substance indicates acceptance of the problem, which is the first step of the recovery process.
5. The nurse is assessing a client diagnosed with schizophrenia and asks, "Do you ever get messages through things, like the television or microwave?" Which symptom of schizophrenia is the nurse assessing for? 1. Illusions 2. Circumstantiality 3. Hallucinations 4. Delusions of reference
Answer: 4 This is correct. The nurse is assessing for delusions of reference. Delusions are fixed false beliefs that an individual maintains are true despite evidence to the contrary. Delusions of reference are characterized by an individual's perception that events within the environment have meaning specific to himself or herself.
10. The nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? 1. To assess for emotional strength and regret 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for tachycardia 4. To assess for fine tremors
Answer: 4 This is correct. The nurse is assessing the client for fine tremors resulting from alcohol withdrawal. Other symptoms of alcohol withdrawal include headache, insomnia, transient hallucinations, depression, severe agitation, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizures.
16. A client diagnosed with MDD states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which statement by the nurse best assesses this client's affective symptoms? 1. "Have you been diagnosed with any physical disorder within the past 3 months?" 2. "Have you ever felt this way before? 3. "People who have mood changes often feel better when spring comes." 4. "Help me understand what you mean when you say 'feeling down'."
Answer: 4 This is correct. The nurse is using the therapeutic communication technique of clarifying to assess the client's symptoms. Open-ended questions elicit more information than closed-ended questions. A closed-ended question will yield a "yes" or "no" answer.
14. Which medication orders should the nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Carbamazepine (Tegretol) and donepezil (Aricept) 3. Disulfiram (Antabuse) and lorazepam (Ativan) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)
Answer: 4 This is correct. The nurse should anticipate a medication order for chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client with a history of complicated withdrawal from benzodiazepines. The anticonvulsant phenytoin (Dilantin) is indicated because complicated withdrawal may include seizures. Chlordiazepoxide (Librium) is used to treat alcohol withdrawal.
1. A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."
Answer: 4 This is correct. The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.
14. An elderly client recently moved to a nursing home. The client is having trouble concentrating and is isolating from others. A physician believes the client would benefit from medication therapy. Which medication would the nurse expect the physician to prescribe? 1. Haloperidol 2. Donepezil 3. Diazepam 4. Sertraline
Answer: 4 This is correct. The nurse should expect the physician to prescribe sertraline (Zoloft), a selective serotonin reuptake inhibitor (SSRI) antidepressant, to improve the client's social functioning and concentration levels. SSRIs are considered by many to be the first-line drug treatment for depression in the elderly because of their favorable side-effect profile.
24. The nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepin (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? 1. Imipramine (Tofranil) 2. Doxepin (Sinequan) 3. Ziprasidone (Geodon) 4. Tranylcypromine (Parnate)
Answer: 4 This is correct. The nurse should order a special diet for the client receiving the MAOI tranylcypromine (Parnate). Hypertensive crisis occurs in clients receiving an MAOI who consume foods or medications with a high tyramine content.
11. A client diagnosed with an NCD due to late-stage Alzheimer's disease is incapable of performing ADLs. Which intervention is the nurse's priority? 1. Present evidence of objective reality to improve cognition. 2. Design a bulletin board to represent the current season. 3. Label the client's room with name and number. 4. Assist the client with bathing and toileting.
Answer: 4 This is correct. The nurse's priority is to assist with bathing and toileting. A client who is incapable of performing ADLs requires assistance in these areas to ensure health and safety.
3. A client diagnosed with a neurocognitive disorder (NCD) due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes that these symptoms indicate which stage of the illness? 1. Moderate cognitive decline 2. Very mild change 3. Moderately severe cognitive decline 4. Very severe cognitive decline
Answer: 4 This is correct. The very severe cognitive decline stage is characterized by a severe cognitive decline. Speech and language are severely impaired, with greatly decreased verbal communication. The person may no longer recognize any family members. Muscles are rigid, contractures may develop, and primitive reflexes may be present.
11. Which nursing action is most appropriate to establish trust with a suspicious client? 1. Maintain consistent staff assignments. 2. Reinforce and focus on reality. 3. Maintain low environmental stimuli. 4. Use a passive communication approach.
Answer: 4 This is correct. Use of passive communication is a patient-centered approach that helps establish trust and allows the patient the opportunity to make his or her decisions about activities and treatment goals.
29. The nurse notes elevated levels of prolactin while reviewing the laboratory results of a client diagnosed with schizophrenia. Which symptoms should the nurse expect to assess? Select all that apply. 1. Apathy 2. Social withdrawal 3. Anhedonia 4. Galactorrhea 5. Gynecomastia
Answer: 4, 5 4: This is correct. Galactorrhea is a milky nipple discharge unrelated to the normal milk production of breastfeeding related to elevated prolactin levels. Antipsychotic medications can cause elevated prolactin levels by blocking dopamine receptors. 5: This is correct. Gynecomastia is an enlargement or swelling of breast tissue in males related to elevated prolactin levels. Antipsychotic medications can cause elevated prolactin levels by blocking dopamine receptors.
