Mental Health Exam 4

9. A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.

A The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression.

6. A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will this cure Alzheimer's disease (AD)?" Which is the appropriate instructor reply? A. "This medication 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 AD." B. "This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." C. "This medication 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 AD." D. "This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."

A The most appropriate response by the instructor is to explain that donepezil (Aricept) 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 AD.

1. A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. "Taking multiple medications may lead to adverse interactions or toxicity." B. "Age-related cognitive changes may lead to alterations in mental status." C. "Lack of rigorous exercise may lead to decreased cerebral blood flow." D. "Decreased social interaction may lead to profound isolation and psychosis."

A The nurse should identify that 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. The client with delirium is disoriented to time and place and may also have impaired memory.

Samuel, a 19-year-old high school student, has been admitted to the psychiatric unit with a diagnosis of adjustment disorder with disturbance of conduct. He assaulted a teacher when he was told he was receiving detentions for a pattern of tardiness. The nurse, while completing rounds, finds the patient in his room crying, and one of his wrists is bleeding from a self-inflicted cut made by a piece of metal from an unknown source. Prioritize each of the following nursing interventions from 1 to 5, with 1 being the highest priority. ___ A. Check the patient's vital signs. ___ B. Assess the wound site. ___ C. Contact the parents. ___ D. Discuss with Samuel what precipitated this event. ___ E. Cleanse and treat the wound site to prevent infection.

ANS: A: 3 B: 1 C: 5 D: 4 E: 2 The first priority is assessment (Item B), followed by providing care to meet physical and safety needs (Items E and A). The next priority is responding to the patient's emotional needs (Item D), and finally, contacting the patient's parents (Item C) in accordance with standards for confidentiality of medical information. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Management of Care

A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills

ANS: A A client raised in an 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 realistically appraise distorted responsibility and dysfunctional guilt. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide.

ANS: A Clients who have specific plans are at greater risk for suicide. KEY: Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Safe and Effective Care Environment

A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? A. Assessing the client's pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurse-client relationship

ANS: A It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A military vet who recently returned from active duty in a Middle Eastern country and suffers from PTSD states he will not allow the lab tech, who is Iranian, to draw his blood. The patient states "He'll probably use a contaminated needle on me". Which of these is the most appropriate response by the nurse? A. "Let me see if I can arrange for a different technician to draw your blood." B. "Let me help you overcome your cultural bias by letting him draw your blood." C. "There is no other technician, so you're just going to have to let him draw your blood." D. "I don't think the technician is really Middle Eastern."

ANS: A Item A demonstrates acceptance of the patient and attempts to create a less threatening situation for the patient. Item B makes an unsubstantiated assumption about the patient's biases. Item C will not contribute to the patient's sense of control, and sense of comfort and control is important in managing symptoms of PTSD. Item D minimizes the patient's concerns rather than responding empathically to them. KEY: Cognitive Level: Application | Integrated Processes: Caring | Client Need: Psychosocial Integrity

Paula's husband returned from active duty 1 month ago, and Paula is now seeing a counselor for relational conflict in her marriage. She tells the counselor she thinks her husband "can't love anything as much as he loves the military" and that "he acts like he can't wait to be redeployed." Which of these common aspects about military culture might be contributing to her husband's behavior? A. Military mission is advanced as the highest priority. B. Marriage is discouraged in the military. C. Redeployment is considered the highest honor. D. People who choose a military lifestyle often have asocial personality traits.

ANS: A One aspect of military culture is advancing the idea that the military mission takes precedence over other concerns, which could be perceived to include family and marital relationships. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. "I am sad most of the time and I've felt this way for the last several years." B. "I find myself preoccupied with death." C. "Sometimes I hear voices telling me to kill myself." D. "I'm afraid to leave the house."

ANS: A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

2. A son who recently brought his extremely confused parent to a nursing home for admission reports feelings of guilt. Which is the appropriate nursing reply? A. "People often have mixed emotions about decisions like this. Support groups are held here on Mondays for children of residents in similar situations." B. "You did what you had to do. I wouldn't feel guilty if I were you." C. "Support groups are available to low-income families." D. "Your parent is doing just fine. We'll take very good care of him."

ANS: A The most appropriate reply by the nurse is to normalize the son's feelings and provide a resource to help the son deal with feelings of guilt by giving information about an available support group.

11. An elderly client has met the criteria for a diagnosis of major depressive disorder. The client does not respond to antidepressant medications. Which treatment should a nurse anticipate that the physician would prescribe for this client? A. Electroconvulsive therapy (ECT) B. Neuroleptic therapy C. An antiparkinsonian agent D. An anxiolytic agent

ANS: A The nurse should anticipate that ECT will be ordered to treat this client's symptoms of depression. ECT remains one of the safest and most effective treatments for major depressive disorder in older adults. When a client does not respond to antidepressant medications or has been diagnosed with co-morbid disease processes that prohibit the use of antidepressant medications, ECT is considered the treatment of choice. The response to ECT may be slower in older clients, and the effects may be of limited duration.

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread." KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, "Do you ever think about killing yourself?" B. Ask client, "Please rate your mood on a scale from 1 to 10." C. Establish a trusting nurse-client relationship. D. Apply the nursing process to the planning of client care.

ANS: A The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Mary is seeing her family physician for a routine checkup and mentions to the nurse that her husband just returned from active duty in the military. He was deployed to Iraq for the last 18 months, and Mary says she is very excited that they will finally be able to "pick up" where they left off. The nurse decides to ask more questions about their marital relationship in this post-deployment period. What is the best rationale for including these assessment questions? A. The post-deployment period is often the most difficult time period for veterans and spouses to negotiate. B. All veterans experience some PTSD and are unable to return to previous relationship patterns. C. Denial about the impact of combat experiences is common in military spouses. D. Mary is most likely being abused by her husband and is covering this up.

ANS: A There is no evidence that denial is common in military spouses, and although physical aggression is a common symptom of PTSD, there is no report of PTSD symptoms in this case. Furthermore, not all veterans experience PTSD. However, knowing that the post-deployment period has been identified as the most difficult period for couples to negotiate, the nurse may find it beneficial to assess their relationship and provide an opportunity for education and resources as needed. KEY: Cognitive Level: Evaluation | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance

A patient admitted to the hospital with PTSD is ordered the following medications. Which of these medications has a direct use in treating symptoms that are common in PTSD? Select all that apply. A. Alprazolam B. Propanolol C. Colace D. Dulcolax

ANS: A, B Alprazolam is an antianxiety agent and anxiety symptoms are common in PTSD. Propanolol is an antihypertensive medication and evidence has demonstrated its effectiveness in treating symptoms of PTSD, including nightmares, intrusive recollections, and insomnia. The last two medications are used to treat constipation, and this symptom is not directly related to PTSD. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient's wife reports to the nurse that she was told her husband's PTSD may be related to cognitive problems. She is asking the nurse to explain what that means. Which of the following are accurate statements about the cognitive theory as it applies to PTSD? Select all that apply. A. People are vulnerable to trauma-related disorders when their fundamental beliefs are invalidated. B. Cognitive theory addresses the importance of how people think (or cognitively appraise) events. C. Dementia is a common symptom of PTSD. D. Amnesia is the biggest cognitive problem in PTSD and is the primary cause of trauma-related disorders.

ANS: A, B Both A and B address aspects of cognitive theory and its relevance in PTSD. Dementia includes cognitive symptoms but is not a symptom of PTSD. Amnesia does not cause PTSD but is a symptom of PTSD. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Joe, a patient being treated for PTSD, tells the nurse that his therapist is recommending cognitive therapy. He asks the nurse how that's supposed to help his nightmares. Which of these responses by the nurse provides accurate information about the benefits of this type of therapy? Select all that apply. A. The nightmares may be related to troubling thoughts and feelings; cognitive therapy will help you explore and modify those thoughts and feelings. B. It is designed to help you cope with anxiety, anger, and other feelings that may be related to your symptoms. C. It is designed to repeatedly expose you to the trauma you experienced so you can regain a sense of safety. D. Once you learn to repress these troubling feelings, the nightmares should cease.

ANS: A, B Both A and B are desired outcomes in cognitive therapy. Item C more aptly describes prolonged exposure therapy. D is incorrect because exploration and awareness (rather than repression) are fundamental to cognitive therapy. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

John is being treated for PTSD symptoms, which began shortly after his retirement from the military. He has had nightmares, flashbacks of traumatic events from combat, and episodes of acute anxiety. His wife is asking the nurse how he could be developing PTSD at this time when he hasn't been in a combat situation for over 10 years. Which of these teaching points are evidence-based pieces of information to share with John's wife? Select all that apply. A. Retirement has been identified as a common precipitating factor for PTSD. B. PTSD symptoms may develop at any time after a trauma. C. PTSD is not the appropriate diagnosis, according to DSM-5, unless the trauma occurred greater than 5 years ago. D. This is probably not PTSD but rather a brief adjustment reaction to retirement.

ANS: A, B Retirement has been identified as a common precipitating factor for PTSD, but symptoms may develop at any time. The DSM-5 establishes symptoms occurring and/or persisting beyond 3 months following a trauma as indicative of PTSD. KEY: Cognitive Level: Synthesis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

A military veteran is being assessed for outpatient therapy after he reports having problems at home and at work. Which of the symptoms that he describes are commonly associated with PTSD? Select all that apply. A. "I've been drinking and smoking pot daily." B. "I've been having trouble sleeping and I think I've been having nightmares but I can't remember them." C. "I slapped my wife when she was trying to hug me." D. "I've been having intense pain in the leg where I sustained a combat wound."

ANS: A, B, C Common symptoms associated with PTSD include substance abuse, sleep disturbances, nightmares, and aggression. Whereas the combat exposure and wounding could be described as traumas, the patient's complaint of pain requires further physical assessment rather than assuming this symptom is related to PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Joshua recently moved into a dormitory to begin his freshman year in college. He was reprimanded by the dormitory supervisor for not properly disposing of food items and responded by throwing all of his belongings from a second story window while shouting obscenities. The campus police escorted him to campus health services, where he was diagnosed with an Adjustment Disorder with Disturbance of Conduct. Which of the following items in Joshua's history predispose him to this disorder? Select all that apply. A. Joshua reports that he doesn't have any friends in the dormitory. B. Joshua's family currently lives out of the country and are often difficult to reach. C. Joshua was notified the same day that he would have to withdraw from one of his classes because he didn't have the prerequisite credits needed to register for the class. D. Joshua has a higher than average GPA and is a member of The National Honor Society.

ANS: A, B, C Items A and B may suggest lack of available support systems, which is identified as a predisposing factor for Adjustment Disorders. Item C presents evidence of another stressor occurring in proximity to the reprimand from the dormitory supervisor, which may also predispose to the development of an Adjustment Disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply. A. "I can't believe this is happening." B. "If only I had been more understanding." C. "How dare he do this to me!" D. "I'm just going to have to accept that he was gay." E. "Well, that was a selfish thing to do."

ANS: A, B, C Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father. The last two possible responses suggest acceptance and understanding. It is far more common for survivors of suicide to have a sense of feeling wounded and as if they will never get over it. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient is admitted to the community mental health center for outpatient therapy with a diagnosis of Adjustment Disorder. Which of the following subjective statements by the patient support this diagnosis? Select all that apply. A. "I was divorced 3 months ago and I can't seem to cope." B. "I was a victim of date rape 15 years ago when I was in college." C. "My partner came home last week and told me he just didn't love me anymore." D. "I failed one of my classes last month and I can't get motivated to register for my next semester."

ANS: A, C, D A diagnosis of Adjustment Disorder is appropriate when the stressors are related to relational conflict, where there are significant emotional or behavioral symptoms, and when the response occurs within 3 months after the onset of the stressor (and persists no longer than 6 months). Item B would be more aptly described as a traumatic event. KEY: Cognitive Level: Evaluation | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

ANS: A, C, D Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post-menses KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A patient who is being seen in the community mental health center for PTSD is being considered for EMDR (Eye Movement Desensitization and Reprocessing) therapy. The nurse is being asked to conduct an assessment to validate the patient's appropriateness for this treatment. Which of the following pieces of data, collected by the nurse, are most important to document when determining appropriateness for treatment with EMDR? Select all that apply. A. The patient has a history of a seizure disorder. B. The patient has a history of ECT. C. The patient reports suicidal ideation with a plan. D. The patient has been using alcohol in increasing quantities over the last 3 months.

ANS: A, C, D Items A, C, and D are all factors that would contraindicate the use of EMDR. A history of ECT is not directly relevant in determining appropriateness for EMDR. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Documentation | Client Need: Safe and Effective Care Environment

A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply. A. In the Middle Ages, suicide was viewed as a selfish and criminal act. B. During the Roman Empire, suicide was followed by incineration of the body. C. Suicide was an offense in ancient Greece, and a common-site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically. E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

ANS: A, C, D These are true historical facts about suicide and should be included in the student's study guide. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Les has been referred to the VA clinic because he was recently fired from his job. His former employer reported that he was drinking on the job and had become physically aggressive with one of his coworkers. Which of the following statements during the intake assessment are consistent with common symptoms of PTSD? Select all that apply. A. "I've been drinking and smoking pot more frequently in the past few months." B. "I've always thought I was too good for that job anyway." C. "Sometimes I get so angry I just want to punch someone's lights out." D. "I haven't been getting enough sleep because the nightmares keep waking me up." E. "I don't like authority figures."

ANS: A, C, D Substance abuse, aggression, insomnia, and nightmares are all symptoms commonly associated with PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Jane has begun treatment for PTSD with symptoms of depression. The nurse is reviewing the physician's orders. Which of these are evidence-based modalities for initial treatment of Jane's illnesses? Select all that apply. A. Acupuncture B. Electroconvulsive therapy (ECT) C. Sertraline (Zoloft) D. Cognitive behavior therapy (CBT) E. Propranolol (Inderal)

ANS: A, C, D, E Acupuncture, SSRIs, CBT, and antihypertensives such as propranolol have been shown to be effective in treating symptoms of PTSD. ECT has not been identified as an effective treatment of symptoms of PTSD and would not be a first-line treatment for depression. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment: Management of Care

A nurse who works on an inpatient psychiatric unit is working on developing a treatment plan for a patient admitted with PTSD. The patient, a military veteran, reports that sometimes he thinks he sees bombs exploding and the enemy rushing toward him. He has had aggressive outbursts and was hospitalized after assaulting a coworker during one of these episodes. Which of these interventions by the nurse are evidence-based responses? Select all that apply. A. Collaborate with the patient about how he would like staff to respond when he has episodes of re-experiencing traumatic events. B. Tell the patient it is not appropriate to hit other patients or staff and if that occurs he will have to be discharged from the hospital. C. Contact the doctor and recommend that the patient be ordered an antipsychotic medication. D. Refer the patient to a support group with other military veterans.

ANS: A, D Collaborating with the patient demonstrates an environment of mutual respect and is helpful in establishing a trusting relationship. Both of these are identified as essential in effective treatment of PTSD. Evidence also supports that a group with other people who have experienced similar traumas is helpful in reducing the sense of isolation that some people with PTSD experience. Items B and C are incorrect since they both reflect an inaccurate understanding of the dynamics of PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Joe, who recently lost both parents in a tragic automobile accident, has been diagnosed with an adjustment disorder after he struck a friend who told him he needed to "get his feelings out." The stage of grieving that Joe is struggling with is ___________________.

ANS: Anger The stages of grieving include denial, anger, bargaining, depression, and resolution. Joe is expressing anger but in a way that is impairing his relationships with others. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Jane presents in the Emergency Department with a friend, who reports that Jane has been sitting in her apartment "staring off into space" and doesn't seem interested in doing anything. During the assessment Jane reveals, with little emotion, that she was raped 4 months ago. Which of these is the most appropriate interpretation of Jane's lack of emotion? A. Jane is probably hearing voices telling her to be emotionless. B. Jane is experiencing numbing of emotional response, which is a common symptom of PTSD. C. Jane is trying to be secretive, and lying is a common symptom in PTSD. D. Jane is currently re-experiencing the traumatic event and is having a dissociative episode.

ANS: B General numbing of emotional response is a common symptom of PTSD. Items A and D are not the most appropriate interpretations because the data are inadequate to make that inference. Item C is incorrect; lying is not a common symptom in PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship.

ANS: B Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, and measureable and contain a time frame. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? A. "Your grieving will subside within 1 year; until then I recommend antidepressants." B. "Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area." C. "The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them." D. "Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone."

ANS: B Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence, and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

ANS: B 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. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Brandy is an 18-year-old being treated in the Community Mental Health Clinic for an adjustment disorder after receiving news of her parents' impending divorce. While talking about her feelings she becomes angry and starts shouting and crying. She screams, "I wish they would both die!" Which of these is the most appropriate response by the nurse at this point? A. Contact the parents and the police to report that Brandy is expressing homicidal ideation. B. Encourage Brandy to talk more about her anger. C. Instruct Brandy that it's okay to cry but that it is not acceptable to talk that way about her parents. D. Assess Brandy for suicidal ideation.

ANS: B It is important in treating patients with adjustment disorders to allow them to express anger. Item C discourages the patient from expressing anger. Items A and D would be premature, since there is inadequate evidence to warrant those responses. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

6. Which psychiatric disorder would a nurse expect to see diagnosed in a client's later life? A. Schizophrenia B. Major depressive disorder C. Phobic disorder D. Dependent personality disorder

ANS: B Major depressive disorder is most likely to be identified later in life. Depression among older adults can be increased by physical illness, functional disability, cognitive impairment, and loss of a spouse.

What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

4. A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? A. "Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives." B. "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." C. "Reminiscence therapy is a social group where members chat about past events and future plans." D. "Reminiscence therapy encourages members to share positive memories of significant life transitions."

ANS: B Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution. Stimulation of life memories serves to help older clients work through their losses and maintain self-esteem. Reminiscence therapy can take place in one-on-one or group settings.

12. According to the U.S. Census Bureau criteria, how would a nurse classify a 70-year-old man? A. This man would be classified as "older." B. This man would be classified as "elderly." C. This man would be classified as "aged." D. This man would be classified as "very old."

ANS: B The U.S. Census Bureau classifies a 70-year-old man as "elderly." The U.S. Census Bureau has developed a system for classification of older Americans: older, 55 to 64; elderly, 65 to 74; aged, 75 to 84; very old, 85 years and older.

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.

ANS: B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment: Management of Care

3. A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the appropriate nursing reply? A. "I'm glad we discussed this. We'll excuse him from the activity groups." B. "The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation." C. "The groups are optional. Only clients at high functioning levels would benefit." D. "If your father doesn't go to these activity groups, he will be at high risk for developing dementia."

ANS: B The most appropriate nursing reply is to educate the family on the purpose of activity groups, which is to provide social interaction, sensory stimulation, and reality orientation. Groups can also serve to increase self-esteem and reduce depression.

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge? A. "I must observe you continually for 1 hour in order to keep you safe." B. "Let's confer with the treatment team about the resources that you may need after discharge." C. "You must have been very upset to do what you did today." D. "Are you currently thinking about harming yourself?"

ANS: B The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss client problems and needs. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

8. An elderly, emaciated client is brought to an emergency department by the client's caregiver. The client has bruises and abrasions on shoulders and back in multiple stages of healing. When directly asked about these symptoms, which type of client response should a nurse anticipate? A. The client will honestly reveal the nature of the injuries. B. The client may deny or minimize the injuries. C. The client may have forgotten what caused the injuries. D. The client will ask to be placed in a nursing home.

ANS: B The nurse should anticipate that the client might deny or minimize the injuries. The older client may be unwilling to disclose information because of fear of retaliation, embarrassment about the existence of abuse in the family, protectiveness toward a family member, or unwillingness to bring about legal action.

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread." KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Major Smith, who is being treated for PTSD symptoms following a course of military duty, reports, "I think I was in denial about even having PTSD. I thought I was just having trouble sleeping." Which of these is an accurate evaluation of the patient's comments? A. The patient is still in denial and unable to recognize that he is having flashbacks rather than insomnia. B. The patient is beginning to recognize stages of grieving and reevaluating his symptoms. C. The patient is beginning to recognize that he may be at risk for suicide. D. The patient is trying to avoid discussing symptoms of PTSD.

ANS: B The patient is expressing recognition that he was in denial, which is a stage of grieving. It is not uncommon for people to recognize that they are having troubling symptoms but not immediately recognize this as PTSD. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and done with these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care? A. "Have there been any changes in appetite or sleep?" B. "How often is your spouse left alone?" C. "Has your spouse been following a diet and exercise program consistently?" D. "How would you characterize your relationship with your spouse?"

ANS: B This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death among the elderly. D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

ANS: B This factual information should be included in the nursing instructor's teaching plan. An expressed desire to die is not normal in any age group. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

A patient being treated for symptoms of PTSD following a shooting incident at a local elementary school reports "I feel like there's no reason to go on living when so many others died." Which of these is the most appropriate response by the nurse at this juncture? A. "You've got lots of reasons to go on living" B. "Are you having thoughts of hurting or killing yourself?" C. "You're just experiencing survivor guilt." D. "There must be something that gives you hope."

ANS: B This patient is expressing hopelessness, and it is a priority to assess for suicide ideation in these circumstances. Items A and D minimize the patient's experience of feeling hopelessness. Item C may be a useful strategy to encourage the patient that this is a common experience of trauma survivors, but the immediate priority is determining patient safety. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity

A mother brings her son to the Emergency Department and tells the nurse that her son must have PTSD, because 2 days ago he witnessed a car accident in which there were fatalities. She is convinced that her son has PTSD because he has been crying when he talks about the incident. She believes that boys are at greater risk for PTSD because they don't typically cry. She read on the internet that PTSD can have dangerous consequences, so she wants her son to get some medication "to cure the PTSD before it gets too bad." Which of these statements by the nurse would accurately correct this mother's misunderstanding about PTSD? Select all that apply. A. There are no long-term or dangerous consequences from PTSD. B. Women appear to be at greater risk of this disorder than men. C. Medications have been found to be effective in treating symptoms of depression or anxiety but do not represent a cure for the disorder. D. Fewer than 10% of trauma victims develop PTSD.

ANS: B, C, D Items B, C, and D are evidence-based pieces of information. Item A is incorrect since, in fact, dangerous consequences of unmanaged PTSD may include depression and/or suicide. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

ANS: C A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide? A. Family history of depression B. The client's orientation to reality C. The client's history of suicide attempts D. Family support systems

ANS: C A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client's risk. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimer's disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

Joshua, a 15-year-old whose father has been suffering from PTSD since returning from combat, is now seeing a counselor himself with reports of "flashbacks" that are similar to his father's symptoms. Which of the following interpretations of Joshua's behavior is supported by evidence? A. Military children often pretend to have symptoms of PTSD to get secondary gains. B. This is a common symptom of substance abuse and drug-seeking behavior. C. It is not uncommon for children of parents with PTSD to experience secondary trauma. D. Joshua's experience is indicative of impending psychosis.

ANS: C Children and caregivers of people with PTSD have been identified as at risk for similar PTSD symptoms as a result of secondary trauma. KEY: Cognitive Level: Application | Integrated Processes: Caring | Client Need: Psychosocial Integrity

The nurse is providing counseling to clients diagnosed with major depressive disorder. 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? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |Client Need: Psychosocial Integrity

A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client's belief system, the nurse should conclude which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

ANS: C Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment

Studies have suggested that re-experiencing a traumatic event can become an addiction of sorts. The evidence suggests that the reason for this is: A. People with PTSD often have addictive personalities. B. Perpetuating the traumatic experience yields secondary gains. C. The re-experiencing of trauma enhances production of endogenous opioid peptides. D. People with PTSD often have concurrent substance abuse issues.

ANS: C Hollander and Simeon (2008) report on studies suggesting that the release of endogenous opioid peptides can produce an "addiction to the trauma." There is no evidence suggesting that addictive personality traits are responsible for chronicity in PTSD symptoms. Items B and D are possible outcomes in any individual with PTSD, but neither has been correlated to an "addiction" to re-experiencing trauma. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

Sandy, a rape survivor, is being treated for PTSD. Which of these statements are good indications that Sally is beginning to recover from PTSD? A. "I still have nightmares every night, but I don't always remember them anymore." B. "I'm not drinking as much alcohol as I had been over the last several months." C. "This traumatic event immobilized me for awhile, but I have found imagery helpful in reducing my anxiety." D. All of the above.

ANS: C Item C demonstrates evidence of awareness of the impact the trauma had on Sandy's life and demonstrates evidence of effective coping skills. Item A indicates continued presence of symptoms and possibly amnesia. Although item B may be evidence of a positive coping strategy, evaluation of recovery from PTSD must also include assessment for less symptoms such as nightmares and flashbacks. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this client's symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

ANS: C Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply? A. "Suicide is a DSM-5 diagnosis." B. "Suicide is a mental disorder." C. "Suicide is a behavior." D. "Suicide is an antisocial affliction."

ANS: C Suicide is not a diagnosis, disorder, or affliction. It is a behavior. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

9. A client diagnosed with neurocognitive disorder due to Alzheimer's disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication? A. Discourage attempts at verbal communication because of increased client frustration. B. Increase the volume of the nurse's communication responses. C. Verbalize the nurse's perception of the implied communication. D. Encourage the client to communicate by writing.

ANS: C The most appropriate nursing intervention is to verbalize the nurse's perception of the implied communication. The nurse should also keep explanations simple, use face-to-face interaction, and speak slowly without shouting.

1. A client has recently been placed in a long-term-care facility because of marked confusion and inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the client's self-esteem? A. Leave the client alone in the bathroom to test ability to perform self-care. B. Assign a variety of caregivers to increase potential for socialization. C. Allow client to choose between two different outfits when dressing for the day. D. Modify the daily schedule often to maintain variety and decrease boredom.

ANS: C The most appropriate nursing intervention to maintain this client's self-esteem is to allow the client to choose between two different outfits when dressing for the day. The nurse should also provide appropriate supervision to keep the client safe, maintain consistency of caregivers, and maintain a structured daily routine to minimize confusion

A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.

ANS: C The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

7. An elderly client who lives with a caregiver is admitted to an emergency department for a fractured arm. The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect? A. Inability for the client to meet self-care needs B. Alzheimer's dementia C. Abuse, neglect, or both D. Caregiver role strain

ANS: C The nurse should expect that this client is a victim of elder abuse, neglect, or both. Indicators of elder physical abuse include bruises, fractures, burns, and other physical injuries. Neglect may be manifested as hunger, poor hygiene, unattended physical problems, and/or abandonment.

A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide? A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times

ANS: C The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

10. An elderly client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen? A. Altered cortical and intellectual functioning B. Altered respiratory and gastrointestinal functioning C. Altered liver and kidney functioning D. Altered endocrine and immune system functioning

ANS: C The nurse should question the use of an antidepressant medication in a client with altered liver and kidney function. Antidepressant medication should be administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity. Because of these changes, medications can reach high levels despite moderate oral dosage.

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide

ANS: C The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the client's threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the client's threat must be addressed

ANS: C The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular bloodwork B. The client's mood and affect score, according to the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Sam, a 50-year-old veteran with a traumatic brain injury (TBI), was recently diagnosed with Alzheimer's disease. His sister asks the nurse, "How can this be an accurate diagnosis? There is no incidence of this in our family." Which of these teaching points is accurate for the nurse to share with Sam's sister? A. Alzheimer's disease doesn't tend to run in families. B. Alzheimer's disease is often misdiagnosed in patients with PTSD. C. Alzheimer's disease is more common in patients with TBI than in the general population. D. Alzheimer's disease in patients with TBI is not like traditional Alzheimer's disease.

ANS: C There is a 2.3 times greater incidence of Alzheimer's disease in patients with TBI than in the general population. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

The nurse is conducting an assessment for Don, a 5-year veteran with a traumatic brain injury (TBI). He was referred to the clinic for evaluation of movement disorders. He reports taking alprazolam (Xanax) for the last 3 months and wonders if that is contributing to his tremors and shuffling gait. Which of these understandings is most important in guiding the nurse's further assessment and response to Don? A. Alprazolam (Xanax) has a high risk potential for extrapyramidal side effects. B. Don's symptoms are likely related to alprazolam (Xanax) addiction. C. There is an associated risk for Parkinson's disease in patients with TBI. D. Don's symptoms are most likely symptoms of PTSD.

ANS: C There is an association between TBI and the development of Parkinson's disease. Antipsychotic agents rather than antianxiety agents have a higher risk for extrapyramidal symptoms. Although Don's tremors could signal drug withdrawal, the concurrent shuffling gait suggests a movement disturbance. Finally, movement disturbances are not a symptom of PTSD. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Susan returned from active duty and is being treated for PTSD. She tells the nurse that she was never in a combat zone during her deployment, and her commanding officer told her that you can't have PTSD unless you were in active combat. Which of these responses by the nurse is an accurate reflection about PTSD in military personnel? A. Women may experience other anxiety disorders but rarely experience PTSD as a result of being in the military. B. PTSD after serving in the military is almost always related to trauma associated with active combat. C. Women in the military more often experience PTSD secondary to sexual assault. D. All of the above.

ANS: C Women are at risk for PTSD as a result of experiences in the military, and it is more often secondary to sexual assault rather than combat trauma. The other distractors are incorrect assumptions. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

According to NANDA (2012), a disorder that occurs after the death of a significant other or any loss perceived as significant to the individual, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment, is referred to as________________________.

ANS: Complicated grieving A grieving process that does not follow normative expectations may include fixation at a particular stage of grieving, psychosomatic symptoms, and/or impairment in occupational, social, intellectual, or emotional function. KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Carl is being treated for PTSD after return from military combat. He also sustained a mild traumatic brain injury secondary to an explosive device while in combat. The nurse decides to conduct additional screening assessments on the basis of common comorbidities that occur with these conditions. Which of these screening assessments would be relevant? A. CAGE screen for alcohol abuse B. Beck Depression Inventory C. Mini Mental Status Exam D. All of the above

ANS: D Alcohol abuse and depression are common comorbidities with PTSD. Cognitive deficits, including memory problems, may accompany traumatic brain injury, so all three of these screens would be relevant. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance

A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

ANS: D Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Brian is seeking treatment for PTSD following his tour of duty in a combat zone. He reports to the assessment nurse that he has been smoking pot and drinking alcohol daily for the past 4 days because he just can't stand feeling depressed all the time. Which of these assessments is the highest priority considering Brian's symptoms? A. Amount of current cannabis use B. Marital status C. Neurological assessment D. Suicide risk assessment

ANS: D Because of a high correlation between PTSD, depression, substance abuse, and risk for suicide, the risk for suicide assessment is the highest priority to establish patient safety. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

13. A nurse is conducting a class on fall prevention at a local senior center. In relationship to the slowed cognitive processing of advanced age, which teaching modification would be most appropriate for the nurse to implement? A. Encouraging the clients to use hearing aids if needed B. Avoiding overarticulation C. Minimizing distractive stimuli D. Providing more time for client feedback

ANS: D Because the elderly require more time to assimilate information, the nurse should modify teaching methods to allow more time for older adults to respond to and pose questions.

The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

ANS: D Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "Nothing will help me feel better."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Bill is an only child whose parents are both career military personnel. He is being seen by the school nurse for complaints of fever and wants to be sent home. On examination he is afebrile. He tells the nurse he doesn't like this school anyway and the nurse notes that this is his third school transition in four years. Which of these understandings about the experience of military family members is important to providing compassionate care for this child? A. Military children are more often exposed to unusual viruses, so he should be sent for a complete evaluation and bloodwork. B. Military children are generally healthier than their nonmilitary peers, so he should be given strict consequences for pretending to be ill. C. Children of military personnel are often victims of physical abuse, so he should be asked direct questions about whether or not his parents have been physically aggressive with him. D. Isolation and alienation are common experiences of military family members, so it is important to assess further his adjustment in the current school setting.

ANS: D Isolation and alienation have been identified as a common experience of military family members. This experience may be exacerbated in children by frequent moves and changes in school environments. KEY: Cognitive Level: Application | Integrated Processes: Caring | Client Need: Psychosocial Integrity

A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? A. "Suicidal threats and gestures should be considered manipulative and/or attention-seeking." B. "Suicide is the act of a psychotic person." C. "All suicidal individuals are mentally ill." D. "Fifty to eighty percent of all people who kill themselves have a history of a previous attempt."

ANS: D It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt. All other answer choices are myths about suicide. KEY: Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Safe and Effective Care Environment

Which of these statements by the patient are indications of complicated grieving? A. "I feel like I should have been the one to die in that hurricane." B. "Last year, several of my coworkers died in a hurricane and I still can't go back to work." C. "I've been having incapacitating migraines ever since the memorial services." D. All of the above

ANS: D Item A indicates survivor guilt, and items B and C are both indications that the trauma has contributed to functional impairment. All three are symptoms of complicated grieving. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

ANS: D Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

14. A client diagnosed with glaucoma is being discharged to an assisted living facility. In what way should the discharge nurse modify teaching to most effectively present information to this client? A. Repeat information at least four times. B. Present discharge teaching to client's spouse. C. Use a taped message that can be repeated as needed. D. Reinforce critical content by providing large-print handouts.

ANS: D Providing large-print materials would address the client's visual alterations.

During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements

ANS: D The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the client's suicidal ideations and intent would be necessary. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

5. A couple resides in a long-term care facility. The husband is admitted to the psychiatric unit after physically abusing his wife. He states, "My wife is having an affair with a young man, and I want it investigated." Which is the appropriate nursing reply? A. "Your wife is not having an affair. What makes you think that?" B. "Why do you think that your wife is having an affair?" C. "Your wife has told us that these thoughts have no basis in fact." D. "I understand that you are upset. Let's talk about it."

ANS: D The most appropriate reply by the nurse is to empathize with the client regarding his emotional response and to encourage the client to talk about the situation. The nurse should remain nonjudgmental and help maintain orientation and aid in memory and recognition.

A client diagnosed with major depressive disorder states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's affective symptoms? A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you ever felt this way before? C. "People who have mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

During the planning of care for a suicidal client, which correctly written outcome should be a nurse's first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay.

ANS: D The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority. The "A" answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, and realistic and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment

A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? A. "Why don't you consider doing volunteer work in a homeless shelter?" B. "Let's discuss the negative aspects of your life." C. "Things will look better in the morning." D. "It sounds like you are feeling pretty hopeless."

ANS: D This statement verbalizes the client's implied feelings and allows him or her to validate and explore them. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

16. Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients diagnosed with amnesic disorders? A. Neurocognitive disorders involve disorientation that develops suddenly, whereas amnestic disorders develop more slowly. B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not. C. Neurocognitive disorders include the symptom of confabulation, whereas amnestic disorders do not. D. Both neurocognitive disorders and profound amnesia typically share the symptom of disorientation to place, time, and self.

B Neurocognitive disorders involve impairment of abstract thinking and judgment. Amnestic disorders are characterized by an inability to learn new information and to recall previously learned information, with no impairment in higher cortical functioning or personality change.

13. A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this client's assessment data, which diagnosis would the nurse expect the physician to assign? A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimer's disease

B The nurse should expect that this client would be diagnosed with vascular neurocognitive disorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abrupt onset. This disease often occurs in a fluctuating pattern of progression.

7. Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)? A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity

B The nurse should identify that attention and concentration are impaired in neurocognitive disorder and not in pseudodementia (depression).

4. A client is in the late stage of Alzheimer's disease. To address the client's symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.

C

12. A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

C The initial nursing action is to assess environmental triggers and potential unmet needs. Due to the cognitive decline experienced in a client diagnosed with neurocognitive disorder, communication skills may be limited. The client may become disoriented and frustrated.

8. At what time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications

C The nurse should determine that clients with Alzheimer's disease exhibit more pronounced symptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the late afternoon and evening.

10. After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimer's disease. What should cause the nurse to question this diagnosis? A. Neurocognitive disorder does not typically occur in African American clients. B. The symptoms presented are more indicative of Parkinsonism. C. Neurocognitive disorder does not develop suddenly. D. There has been no T3 or T4 level evaluation ordered.

C The nurse should know that neurocognitive disorder (NCD) does not develop suddenly and should question this diagnosis. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed. The disease is generally progressive and debilitating.

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. A nurse should recognize these as classic signs of which condition? A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism

C The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). In NCD, impairment is evident in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate.

15. A client diagnosed with neurocognitive disorder due to Alzheimer's disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis? A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance

C The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury.

2. A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.

D Forgetfulness is an early symptom of dementia that would alert the nurse to question the client's safety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease. The cause of vascular dementia is related to an interruption of blood flow to the brain. High blood pressure and hypertension are significant factors in the etiology.

14. An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft)

D The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the client's social functioning and concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder.

3. A client diagnosed with neurocognitive disorder 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 these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

D The nurse should recognize that this client is in the late stage of Alzheimer's disease. The late stage is characterized by a severe cognitive decline.

11. A client diagnosed with neurocognitive disorder due to Alzheimer's disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the client's room with name and number D. Assist with bathing and toileting

D The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.