Practice Questions for Exam 2 Mental Health

Test-Taking Tip 1:

After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

A community mental health nurse counsels a group of patients about the upcoming flu season. What instruction does the nurse provide for patients who are prescribed lithium? a. "Stop taking your medicine and contact me if you have nausea, vomiting, and/or diarrhea." b. "Remember that lithium reduces your immunity, so you are more vulnerable to catching the flu." c. "The flu is contagious. Isolate yourself if you get the flu so that you avoid exposing others to it." d. "Because you take lithium, you may have flu symptoms that are not typically experienced by others."

Answer - a. Page 236 (Box 16-1). Patients should stop taking lithium if excessive diarrhea, vomiting, or sweating occurs. These problems can lead to dehydration, which can raise serum lithium to toxic levels.

A patient diagnosed with schizophrenia says, "I hear the voices every day. They always say bad things about me." Which action by the nurse has the highest priority? a. Assess the patient for suicidal thinking and plans. b. Review the patient's medication regime and compliance. c. Educate the patient about symptoms associated with schizophrenia. d. Suggest distracters for the patient to use when auditory hallucinations occur.

Answer - a. Page 245. The daily experience of negativity creates a scenario in which the risk for suicide is high. Depressive symptoms occur frequently in schizophrenia. Suicide is the leading cause of premature death in this population.

The parent of an adolescent recently diagnosed with schizophrenia says to the nurse, "This is entirely my fault. I should have spent more time with my child when he was a toddler." Which response by the nurse is correct? a. "Schizophrenia is genetically transmitted, so it was not in your control." b. "Your child's disorder is more likely the result of an undetected head injury." c. "Environmental toxins are directly implicated in the origins of schizophrenia." d. "Lack of prenatal care causes schizophrenia rather than early childhood events."

Answer - a. Page 406. Genetic factors have been implicated in a number of childhood mental disorders, including autism, bipolar disorders, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), intellectual developmental disorders, and some others.

A patient diagnosed with bipolar disorder lives in the community and is showing early signs of mania. The patient says, "I need to go visit my daughter but she lives across the country. I put some requests on the Internet to get a ride. I'm sure someone will take me." What is the nurse's most therapeutic response? a. "I'm concerned about your safety when meeting or riding with strangers." b. "Have you asked friends and family to donate money for your airfare?" c. "You are not likely to get a ride. Let's consider some other strategies." d. "Have you asked your daughter if she wants you to come for a visit?"

Answer - a. Pages 230-231. Safety is a priority. Mania impairs the person's judgment and impulse control, which may result in harm to self. The correct response identifies potential dangers and shows care for the patient.

Which comment by a patient diagnosed with bipolar disorder best indicates the patient is experiencing mania? a. "I have been sleeping about 6 hours each night." b. "Yesterday I made 487 posts on my social network page." c. "I am having dreams about my father's death 8 years ago." d. "My appetite is so robust that I've gained 4 pounds in the past 2 weeks."

Answer - b. Page 229. Numerous posts on a social network page indicate hyperactivity, which is a hallmark of mania.

A patient smiles broadly at the nurse and says, "Look at my clean teeth. I brushed them with scouring power because the label said, 'It brightens and whitens everything.'" Which term should the nurse include when documenting this encounter? a. Circumstantiality b. Concrete thinking c. Poverty of speech d. Associative looseness

Answer - b. Page 248. Concrete thinking refers to the literal interpretation, with an inability to comprehend abstract concepts.

A patient diagnosed with schizophrenia complains to the nurse about persistent feelings of restlessness and says, "I feel like I need to move all the time." What is the nurse's next action? a. Add an activity group to the patient's plan of care. b. Assess the patient for other extrapyramidal symptoms. c. Perform a full mental status evaluation of the patient. d. Educate the patient about psychomotor agitation associated with schizophrenia.

Answer - b. Page 268 (Table 17-10). The patient's comments suggest that akathisia, which is an extrapyramidal symptom, is occurring. The nurse should assess the patient for other indicators of this side effect of antipsychotic medication.

Which scenario presents the highest risk for a pregnancy resulting in offspring with an intellectual developmental disability (IDD)? a. 18-year-old mother who received no prenatal care b. 32-year-old woman diagnosed with anorexia nervosa c. 26-year-old father with a history of episodic alcohol abuse d. 38-year-old father diagnosed with generalized anxiety disorder

Answer - b. Page 407. Causes of intellectual developmental disability may be a result of hereditary factors, alterations in early embryonic development, pregnancy and perinatal problems, and other factors such as trauma and poisoning.

A nurse plans to lead a group in a residential facility for kindergarten-aged, abused children. Which strategy should the nurse incorporate? a. Building a house using blocks b. Telling a story about a child who felt sad c. Drawing pictures of fun activities at a park d. Reading and discussing a book about abused children

Answer - b. Page 414. Therapeutic interventions should be matched to the developmental level of the child. Abused children are likely to have problems with anxiety or depression. Storytelling is a form of bibliotherapy likely to appeal to kindergarten-aged children. Children unconsciously identify with the characters in the story, allowing self-expression in a safe environment to occur.

An 85-year-old woman says to the nurse, "I raised three children, but now two of them barely speak to me. I did not do a good job of instilling a family spirit." Which response should the nurse provide? a. "Do you think this situation is likely to change?" b. "If you could relive those earlier years, what would you do differently?" c. "There's no guidebook for parenting. Your children have made their own choices." d. "Your children are likely to regret their behavior. I hope you can find it in your heart to forgive them."

Answer - b. Page 445. The developmental task of late life is integrity vs. despair. The patient's comment shows feelings of hopelessness and loss, which contributes to despair. The correct response assists the patient to find meaning in life.

The nurse asks an 87-year-old, "How are you doing?" The patient replies, "I have good days and bad days." Select the nurse's therapeutic response. a. "How is your sleep?" b. "Tell me more about that." c. "Are you feeling depressed?" d. "We expect that from people your age."

Answer - b. Page 445. The patient's comment may relate to physical or mental concerns. The nurse should first clarify and explore the meaning of the comment.

A 92-year-old lives alone but family members assist with transportation and home maintenance. This adult tells the nurse, "They mean well but sometimes my family treats me like a child." What is the nurse's best action? a. Encourage the adult to overlook these behaviors from family members. b. Role-play with the adult ways to share these feelings with family members. c. Contact family members privately and educate them about the harmful effects of ageism. d. Reinforce family members' good intentions and say, "It's fortunate your family is so helpful."

Answer - b. Page 449. As an advocate, the nurse can help to empower the patient to address the problem. Role-playing provides an opportunity to safely practice different responses.

The nurse cares for a hospitalized adolescent diagnosed with major depressive disorder. The health care provider prescribes a low-dose antidepressant. In consideration of published warnings about use of antidepressant medications in younger patients, which action should the nurse employ? a. Notify the facility's patient advocate about the new prescription. b. Teach the adolescent about Black Box warnings associated with antidepressant medications. c. Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior. d. Remind the health care provider about warnings associated with the use of antidepressants in children and adolescents.

Answer - c. Page 211. The possibility that antidepressant medication might contribute to suicidal behavior, especially in children and adolescents, has been a long-time concern and all antidepressants include a black box warning; however, there is no conclusive evidence to support this concern. Use of selective serotonin reuptake inhibitors shows a strong association with a reduction in suicide. All treatments have potential risks; each patient should be considered individually when antidepressants are prescribed. All consumers of antidepressants should be observed carefully for worsening of depression and suicidal thoughts.

Three days after beginning a new regime of haloperidol (Haldol) 10 mg BID, the nurse observes that a hospitalized patient is drooling, has stiff and extended extremities, and has skin that is damp and hot to the touch. The patient has difficulty responding verbally to the nurse. What is the nurse's correct analysis and action in this situation? a. A seizure is occurring; place the patient in a lateral recumbent position and monitor. b. Serotonin syndrome has developed; place an intravenous line and rapidly infuse D5½ NS. c. Neuroleptic malignant syndrome has developed; prepare the patient for immediate transfer to a medical unit. d. An acute dystonic reaction is occurring; promptly administer an intramuscular injection of diphenhydramine (Benadryl).

Answer - c. Page 268 (Table 17-10). Neuroleptic malignant syndrome (NMS) occurs in persons who have taken antipsychotic agents and usually begins early in the course of therapy. It is characterized by a decreased level of consciousness, greatly increased muscle tone, and autonomic dysfunction, including hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic agent, management of fluid balance, reduction of temperature, and monitoring for complications. Treatment of this problem should occur in a medical unit.

The nurse interviews the parent of a 7-year-old child diagnosed with moderate autism spectrum disorder. Which comment from the parent best describes autistic behavior? a. "My child occasionally has temper tantrums." b. "Sometimes my child wakes up with nightmares." c. "My child swings for hours on our backyard gym set." d. "Toilet training was more difficult for this child than my other children."

Answer - c. Page 408. Prominent behavioral characteristics of autism spectrum disorder (ASD) include motions repeated over and over (flaps hands, rocks body, spins self in circles, repeatedly turns light on and off), playing with toys the same way every time, getting upset by minor changes (changes furniture around, changes route going someplace familiar), and obsessive interests.

Which scenario presents the most risk factors for suicide? a. 64-year-old black female whose husband died 3 months ago b. 72-year-old white female scheduled for hip replacement in 2 weeks c. 82-year-old widowed white male recently diagnosed with pancreatic cancer d. 92-year-old black male who recently moved into the home of his adult children

Answer - c. Page 444. The highest suicide rate is among white males age 65 and older. Depression can be dangerous when the older person is also experiencing illness, loneliness, or other life losses.

A 28-year-old second-grade teacher is diagnosed with major depressive disorder. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 years old. Which combination of factors in this scenario best demonstrates the stress-diathesis model? a. Cold climate coupled with history of abuse b. Current age of 28 coupled with family history of depression c. Family history of mental illness coupled with history of abuse d. Female gender coupled with the stressful profession of teaching

Answer - c. Pages 199-200. The stress-diathesis model explains depression from an environmental, interpersonal, and life events perspective combined with biological vulnerability or predisposition (diathesis). Psychosocial stressors and interpersonal events, such as abuse, trigger certain neurophysical and neurochemical changes in the brain. Early life trauma is a significant component in the stress reaction.

A patient experiencing depression says to the nurse, "My health care provider said I need 'talk' therapy but I think I need a prescription for an antidepressant medication. What should I do?" Select the nurse's best response. a. "Which antidepressant medication do you think would be helpful?" b. "There are different types of talk therapy. Most patients find it beneficial." c. "Let's consider some ways to address your concerns with your health care provider." d. "Are you willing to give 'talk therapy' a try before starting an antidepressant medication?"

Answer - c. Pages 200-201. Helplessness is sometimes a finding in major depressive disorder. The nurse has a responsibility for patient advocacy. Helping the patient to advocate for self is empowering.

A patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed medications. The patient says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the nurse's best action. a. Educate the patient about the low odds of winning the lottery. b. Present reality by saying to the patient, "That is not good use of your money." c. Confer with the treatment team about appointing a legal guardian for the patient. d. Tell the patient, "If you buy lottery tickets, your money will run out before the end of the month."

Answer - c. Pages 227, 230-232. The nurse has responsibility for advocacy. In view of the patient's long history of problems, a legal guardian should be considered.

A nurse begins a therapeutic relationship with a patient diagnosed with schizophrenia. The patient has severe paranoia. Which comment by the nurse is most appropriate? a. "Let's begin by talking about the goals you have for yourself." b. "I understand that you have problems with fear and suspiciousness of others." c. "As you get to know me better, I hope you will feel comfortable talking to me." d. "I am part of your treatment team. Our goal is to help stabilize your symptoms."

Answer - c. Pages 252-253. Paranoia causes an inability to trust the actions of others. Therapeutic strategies should focus on lowering the patient's anxiety and decreasing defensive patterns. Application of principles for dealing with paranoia is helpful for establishing trust and rapport

A patient tells the nurse, "No matter what I do, I feel like there's always a dark cloud following me." Select the nurse's initial action. a. Assess the patient's current sleep and eating patterns. b. Explain to the patient, "Everyone feels down from time to time." c. Suggest alternative activities for times when the patient feels depressed. d. Say to the patient, "Tell me more about what you mean by 'a dark cloud'."

Answer - d. Page 198 (Table 15-1). The correct response accomplishes two results: the nurse can further assess the patient's complaint and the nurse uses clarification, a therapeutic communication technique.

Over the past 2 months a patient made eight suicide attempts with increasing lethality. The health care provider informs the patient and family that electroconvulsive therapy (ECT) is needed. The family whispers to the nurse, "Isn't this a dangerous treatment?" How should the nurse reply? a. "Our facility has an excellent record of safety associated with use of electroconvulsive therapy." b. "Your family member will eventually be successful with suicide if aggressive measures are not promptly taken." c. "Yes, there are hazards with electroconvulsive therapy. You should discuss these concerns with the health care provider." d. "Electroconvulsive therapy is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks."

Answer - d. Page 218. Electroconvulsive therapy (ECT) is safe and effective and can achieve a 70% to 90% remission rate in depressed patients within 1 to 2 weeks. ECT is especially indicated when there is a need for a rapid, definitive response when a patient is suicidal or homicidal as well as in selected other circumstances.

A patient was diagnosed with bipolar disorder many years ago. The patient tells the nurse, "When I have a manic episode, there's always a feeling of gloom behind it and I know I will soon be totally depressed." What is the nurse's best response? a. "Most patients diagnosed with bipolar disorder report the same types of feelings." b. "Feelings of gloom associated with depression result from serotonin dysregulation." c. "If you take your medication as it is prescribed, you will not have those experiences." d. "Your comment indicates you have an understanding and insight about your disorder."

Answer - d. Page 239 (Box 16-2). The correct response shows use of the therapeutic communication technique of verbalizing the implied. Gaining insight contributes to relapse prevention.

A community mental health nurse talks with a 6-year-old child whose divorced parents have shared custody. Which initial question will best help the nurse explore the child's perception of home life? a. "Is your life different from your friends' lives?" b. "Are you happiest at your mother's or your father's house?" c. "Do you find it hard to move back and forth between two homes?" d. "What are some of the good and bad things about living in two places?"

Answer - d. Pages 406-407. Developmental level is an important part of the assessment with children, so the nurse should select terms the child will understand. A semistructured interview provides an opportunity for the child to express perceptions about life at home and life at school with teachers and peers. Severe marital discord is a factor that may contribute to mental illness in children.

A nurse assesses a 78-year-old patient who lives alone at home and is beginning three new prescriptions. Which question by the nurse will provide best for the patient's safety? a. "How do you store your medications at home?" b. "What is your usual bowel elimination pattern?" c. "Who usually helps you with your medications?" d. "How much alcohol do you drink on a normal day?"

Answer - d. Pages 445-446. The interaction of drugs and alcohol in the older adult can have serious consequences. Alcohol may prolong, potentiate, or accelerate the metabolism of various drugs.

Test-Taking Tip 8:

Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

Test-Taking Tip 2:

Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Test-Taking Tip 6:

Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.

Test-Taking Tip 9:

Be certain to answer every question. You must arrive at one correct or one "best" answer. If you must, "guess" between two alternatives or eliminate the two or three answers you know are wrong first.

Test-Taking Tip 3:

Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options .

A client is prescribed tricyclic antidepressants. What should the nurse check for in the client's case history before administering the drug? a. Suicidal ideation b. Loss of appetite c. Oral contraceptive use d. Insomnia

Medications such as oral contraceptives, antihypertensive reagents, monoamine oxidase inhibitors, and anticoagulants may react with tricyclic antidepressants. Potent side effects can occur due to drug interaction. The nurse should check for administration in the client's case history and inform the primary healthcare provider. Suicidal ideation, loss of appetite, and insomnia are common symptoms of depression.

Given a choice of the following entrees, what can the client prescribed a monoamine oxidase inhibitor (MAOI) safely eat? a. Avocado salad plate b. Fruit and cottage cheese plate c. Kielbasa and sauerkraut d. Liver and onion sandwich

Monoamine oxidase inhibitors inhibit the breakdown of tyramine, which can lead to high blood pressure, hypertensive crisis, and eventually a cerebrovascular accident. Fruit and cottage cheese do not contain tyramine. Avocados, fermented food such as sauerkraut, processed meat, and organ meat contain tyramine.

Test-Taking Tip 4:

Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

Test-Taking Tip 7:

Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

Test-Taking Tip 5:

Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" What statement by the nurse will be most impactful against this cognitive distortion? a. "Let's look at what you just said, that you can 'never do anything right.'" b. "Tell me what things you think you are not able to do correctly." c. "Is this part of the reason you think no one likes you?" d. "That is the most unrealistic thing I have ever heard."

a. "Let's look at what you just said, that you can 'never do anything right.'" Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate after suggesting that they look at what the client just said. Asking the client to tell the nurse what the client cannot do correctly, asking the client whether this is the reason others do not like him or her, and labeling the client's statement as unrealistic are not helpful to the client.

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? a. Avoidant b. Borderline c. Schizotypal d. Obsessive-compulsive

a. Avoidant The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work. Focus on the subject, a type of personality disorder. Focusing on the words hypersensitivity to a reaction will direct you to the correct option.

A nurse is educating geriatric clients at a community health care center about directives of the Client Self-Determination Act (PSDA). Which statement made by the nurse is appropriate according to the act? a. Clients can give their personal statement of where and how to die in the living will. b. A primary health care provider cannot be a surrogate medical decision maker for the client. c. Clients cannot orally revoke the directive to the primary health care provider. d. Clients have to be terminally ill to allow the empowered individual to act on their behalf.

a. Clients can give their personal statement of where and how to die in the living will. The Client Self-Determination Act (PSDA) of 1990 empowers clients in making decisions about their own health care. Clients can communicate their wishes through a living will in which they can make a personal statement. Clients can mention their wishes of how and where to die. The directive is activated only when the client is terminally ill. In the directive to the health care provider, the client can appoint a health care provider as a surrogate medical decision maker. The health care provider must be the one who diagnosed the client's illness. The directive to the primary health care provider can be terminated orally at any time regardless of the client's ability to make decisions. In durable power of attorney, a person is appointed to act on behalf of the client and can make the client's medical decisions. The client does not have to be terminally ill to appoint a person to make medical decisions on his or her behalf.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. a. Communicate expected behaviors to the client. b. Ensure that the client knows that they are not in charge of the nursing unit. c. Assist the client in identifying ways of setting limits on personal behaviors. d. Follow through about the consequences of behavior in a nonpunitive manner. e. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. f. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

a. Communicate expected behaviors to the client. c. Assist the client in identifying ways of setting limits on personal behaviors. d. Follow through about the consequences of behavior in a nonpunitive manner. f. Have the client state the consequences for behaving in ways that are viewed as unacceptable. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that she or he is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that she or he will not be allowed to attend therapy groups is a violation of a client's rights. Focus on the subject, manipulative behavior. Recalling clients' rights and that power struggles need to be avoided will assist in selecting the correct interventions.

Which change in behavior is important to include when teaching the client and the family to recognize possible signs of impending mania? a. Decreased sleep b. Increased appetite c. Decreased social interaction d. Increased attention to bodily functions

a. Decreased sleep Changes in sleep patterns are especially important, because they usually precede mania. Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania. Increased appetite, decreased social interaction, and increased attention to bodily functions do not indicate impending mania.

Which of the following are more often seen in mental illness in late life? a. Depression and alcohol abuse b. Bipolar disorder with a predisposition to mania c. Schizophrenia, undifferentiated type d. Dissociative disorders

a. Depression and alcohol abuse Depression, risk for suicide, alcohol abuse, and anxiety are all disorders seen in mental illnesses in late life. Although it may be possible to suffer from bipolar disorder with a predisposition to mania, schizophrenia, undifferentiated type, and dissociative disorders in older age, these usually are not first diagnosed in this age group. Clients diagnosed with these disorders earlier in life may in fact have some symptom remission as they age.

A client diagnosed with depression begins a new prescription for phenelzine. Which food is safe for this client to consume? a. Fresh fish b. Pepperoni c. Chocolate d. Guacamole

a. Fresh fish Phenelzine is a monoamine oxidase inhibitor antidepressant medication. It is important to avoid foods high in tyramine. Fresh fish is safe. Pepperoni and chocolate are foods high in tyramine, which may cause a hypertensive crisis. Guacamole is made from avocados, which are also high in tyramine.

Identify the major groups of schizophrenic symptoms. Select all that apply. a. Positive b. Cognitive c. Mood d. Catatonic e. Negative

a. Positive b. Cognitive c. Mood e. Negative The major symptoms of schizophrenia can be grouped into positive, negative, cognitive, and mood. A catatonic state is a mental state that is in the positive group.

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? a. Provide safety for the client and other clients on the unit. b. Provide the clients on the unit with a sense of comfort and safety. c. Assist the staff in caring for the client in a controlled environment. d. Offer the client a less stimulating area in which to calm down and gain control.

a. Provide safety for the client and other clients on the unit. Safety of the client and other clients is the immediate priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients. Note the strategic words, immediate priority, and use Maslow's Hierarchy of Needs theory to prioritize. Note the words agitated, aggressive, and belligerent. Safety is the priority focus if a physiological need does not exist. Also, the correct option is the umbrella option and addresses the safety of all.

Which assessment data are associated with monoamine oxidase inhibitor (MAOI) therapy? Select all that apply. a. Reports dizziness when standing up b. Weight gain of 5 pounds in last 4 weeks c. Heart rate 100 beats per minute and irregular d. Facial twitch noted in left cheek e. Diarrhea for last 3 days

a. Reports dizziness when standing up b. Weight gain of 5 pounds in last 4 weeks c. Heart rate 100 beats per minute and irregular d. Facial twitch noted in left cheek Some common and troublesome long-term side effects of MAOIs are orthostatic hypotension, weight gain, change in cardiac rate and rhythm, and muscle twitching. Diarrhea is not a common side effect, although constipation may occur.

A nurse assesses a 15-year-old who stole and wrecked a neighbor's classic antique car. Two years ago, this adolescent self-inflicted stab wounds. Which nursing diagnosis has priority? a. Risk for suicide b. Ineffective coping c. Impaired adjustment d. Impaired social interaction

a. Risk for suicide Safety is the nurse's priority concern. The number one predictor of suicidal risk is a past suicide attempt, and suicide is the third leading cause of death among 15- to 24-year-olds. Impulsivity and aggression make the possibility of suicide attempts more likely. Ineffective coping, impaired adjustment, and impaired social interaction may apply, but are not the priority.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? a. Setting limits on the client's behavior b. Asking the client to leave the group session c. Asking another nurse to escort the client out of the group session d. Telling the client that they will not be able to attend any future group sessions

a. Setting limits on the client's behavior Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action. Note the strategic word, initially. Eliminate options that are comparable or alike and relate to the client leaving the session. Next, eliminate the option that violates the client's right to receive treatment and is a threatening action. Remember that setting firm limits with the client initially is best.

What genetically determined constitutional factor is defined as the style of behavior habitually used to cope with demands of the environment? a. Temperament b. Creativity c. Conscience d. Attachment

a. Temperament Temperament, the style of behavior habitually used to cope with demands of the environment, is a constitutional factor thought to be genetically determined. This definition does not describe creativity, conscience, or attachment.

What information will be included in medication education for a client prescribed an antidepressant? Select all that apply. a. The goal of antidepressant therapy is the remission of symptoms. b. Antidepressant therapy generally takes one to three weeks for mood to improve. c. Antidepressant therapy may require a change in prescription to identify the most effective antidepressant. d. Antidepressant therapy is contraindicated in clients diagnosed with bipolar disorder. e. Antidepressant therapy may trigger psychosis in clients diagnosed with schizophrenia.

a. The goal of antidepressant therapy is the remission of symptoms. b. Antidepressant therapy generally takes one to three weeks for mood to improve. c. Antidepressant therapy may require a change in prescription to identify the most effective antidepressant. e. Antidepressant therapy may trigger psychosis in clients diagnosed with schizophrenia. The goal of antidepressant therapy is the complete remission of symptoms. A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. Often, the first antidepressant prescribed is not the one that ultimately will bring about remission. Clients with bipolar disorder often receive a mood-stabilizing drug along with an antidepressant. Antidepressants may precipitate a psychotic episode in a person with schizophrenia.

To plan care for a client who is manic, the nurse must consider that lithium cannot be started until what takes place? a. The physical examination and laboratory tests are analyzed. b. The initial doses of antipsychotic medication have brought behavior under control. c. Seclusion has proven ineffective as a means of controlling any assaultive behavior. d. Electroconvulsive therapy can be scheduled to coincide with lithium administration.

a. The physical examination and laboratory tests are analyzed. Lithium may need to be given with caution to patients with impaired renal or thyroid function. A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally. Lithium is a first-line treatment, so it is not likely that the client would receive antipsychotic medication before being treated with lithium. The use of seclusion is not relevant to the use of lithium, and seclusion should be limited. Electroconvulsive therapy may be considered for patients who have not responded to lithium treatment.

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? a. Toxic b. Normal c. Slightly above normal d. Excessively below normal

a. Toxic Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Symptoms of toxicity begin to appear at levels of 1.5 mEq/L (1.5 mmol/L). Lithium toxicity requires immediate medical attention and the primary health care provider is notified if symptoms of toxicity occur. Focus on the subject, therapeutic serum medication level of lithium. Recalling that the high end of the maintenance level is 1.2 mEq/L (1.2 mmol/L) will direct you to the correct option.

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." What should the nurse be prepared to do? a. Wait quietly for the client to reply. b. Prompt the client if the reply is slow. c. Repeat the question if the client does not answer promptly. d. Review the client's medical record to support the client's response.

a. Wait quietly for the client to reply. Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply. The nurse should not rush or pressure the client by prompting the client to reply or repeating the question. There is no need to confirm the client's response with information in the medical record.

The suicide rate is highest for what demographic group? a. White males 65 and older b. Black males 65 and older c. Black females 65 and older d. White females 65 and older

a. White males 65 and older White males aged 65 years and older have the highest rate of suicide. Black males, black females, and white females age 65 years or older have lower suicide rates.

The nurse is caring for a client with an extensive history of alcohol abuse who is experiencing hallucinations. What is the client undergoing? a. Withdrawal b. Relapse c. Mood disorder d. Delusional disorder

a. Withdrawal The client is experiencing a substance-induced psychotic disorder and is displaying withdrawal from alcohol. The client is not experiencing a relapse, mood disorder, or delusional disorder.

An older adult client who is in the terminal stages of liver cancer requests the nurse's assistance in writing an advance directive. What is the most appropriate response by the nurse? a. "Yes, I can write an advance directive on your behalf." b. "No, I cannot assist you in writing an advance directive." c. "I will assist you in drafting the advance directive." d. "You should request the help of a senior nurse in writing the directive."

b. "No, I cannot assist you in writing an advance directive." An advance directive is a written document signed by a client that provides directions to the physicians in case of serious illness. A nurse should be aware of the policies around advance directives and should give information about them to the clients. However, nurses may not assist clients in writing these directives, because this would be considered a conflict of interest. It is also inappropriate to write one on behalf of the client or to inform the client that he or she should request help from a senior nurse.

A nurse is caring for a child diagnosed with posttraumatic stress disorder as a result of violence at home. What trauma interventions should the nurse plan for this child? a. Involve the family in caring for the child. b. Allow the child to draw and play. c. Encourage the child to conceal emotions. d. Limit the child's activities.

b. Allow the child to draw and play. Posttraumatic stress disorder usually occurs after a stressful or traumatic event. Allowing the child to draw and play would help in expression of feelings and improve the child's coping ability. When a child is traumatized due to violence at home, family involvement may disturb the child and should be avoided. The child should be encouraged to identify, explore, and share his or her emotions and to use a variety of activities as an outlet for them.

A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose? a. On an empty stomach b. At the same time each evening c. Evenly spaced around the clock d. As needed when the client complains of depression

b. At the same time each evening Sertraline is classified as an antidepressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline is not prescribed for use as needed. Focus on the subject, administration of sertraline. Recalling that this medication is an antidepressant administered daily will direct you to the correct option.

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? a. Increase socialization of the client with peers. b. Avoid using a whisper voice in front of the client. c. Begin to educate the client about social supports in the community. d. Have the client sign a release of information to appropriate parties for assessment purposes.

b. Avoid using a whisper voice in front of the client. Disturbed thought process related to paranoid personality disorder is the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder. Focus on the subject, interventions for paranoid personality disorder, and note the strategic word, best. Note that the client has paranoia; thinking about its definition will direct you to the correct option.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply. a. Increased heart rate b. Decline in visual acuity c. Decreased respiratory rate d. Decline in long-term memory e. Increased susceptibility to urinary tract infections f. Increased incidence of awakening after sleep onset

b. Decline in visual acuity e. Increased susceptibility to urinary tract infections f. Increased incidence of awakening after sleep onset Anatomical changes to the eye affect the individual's visual ability, leading to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory usually is maintained. Change in sleep patterns is a consistent, age-related change. Older persons experience an increased incidence of awakening after sleep onset. Focus on the subject, normal age-related changes. Read each characteristic carefully and think about the physiological changes that occur with aging to select the correct items.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? a. Check for medication interactions. b. Determine whether there are medication duplications. c. Determine whether a family member supervises medication administration. d. Call the prescribing primary health care provider (PHCP) and report polypharmacy.

b. Determine whether there are medication duplications. Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the PHCP is the intervention after all other information has been collected. Note the strategic word, first. Also note that the nurse is visiting the client for the first time. Options 1, 3, and 4 should be done after possible medication duplication has been identified.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication? a. Cardiovascular symptoms b. Gastrointestinal dysfunctions c. Problems with mouth dryness d. Problems with excessive sweating

b. Gastrointestinal dysfunctions The most common side and adverse effects related to fluoxetine include central nervous system and gastrointestinal system dysfunction. Fluoxetine affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Cardiovascular symptoms, dry mouth, and excessive sweating are not side and adverse effects associated with this medication. Focus on the subject, common side and adverse effects of fluoxetine. It is necessary to remember that this medication causes gastrointestinal problems. This will direct you to the correct option.

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? a. Suppressing feelings of anxiety b. Identifying anxiety-producing situations c. Continuing contact with a crisis counselor d. Eliminating all anxiety from daily situations

b. Identifying anxiety-producing situations Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible. Focus on the strategic words, most appropriate. Eliminate any option that contains the closed-ended word "all" or suggests that feelings should be suppressed. Note that the correct option is more client-centered and helps prepare the client to deal with anxiety should it occur.

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? a. In 2 months b. In 2 to 3 weeks c. During the first week d. During the sixth week of administration

b. In 2 to 3 weeks The maximum therapeutic effects of imipramine may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect time periods. Note the subject, the desired effect of this medication, and focus on the word maximum. Recalling that it takes 2 to 3 weeks for a maximum therapeutic effect to occur with most antidepressants will direct you to the correct option.

The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information should the nurse incorporate in the discussion? a. Consume a low-fiber diet. b. Increase fluids and bulk in the diet. c. Rest if the heart begins to beat rapidly. d. Walk if you have difficulty urinating because this is a normal side effect.

b. Increase fluids and bulk in the diet. Amitriptyline causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the primary health care provider (PHCP) is notified, because this could indicate an adverse effect. Difficulty urinating is an adverse effect and indicates urinary retention; this should also be reported. Focus on the subject, side and adverse effects of amitriptyline. Recalling that constipation is a side effect of this medication will direct you to the correct option.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? a. Decreased absorption of digoxin b. Increased risk for digoxin toxicity c. Decreased therapeutic effect of digoxin d. Increased risk for side effects related to digoxin

b. Increased risk for digoxin toxicity

An elderly client in the terminal stages of lung cancer reports pain. The client tells the nurse, "I wish I could just die." What does the nurse do? Select all that apply. a. Ignore the statement b. Listen to the client's feelings c. Document the statement d. Report to the health care provider e. Ask the client to express more

b. Listen to the client's feelings c. Document the statement d. Report to the health care provider e. Ask the client to express more A terminally ill client may feel hopeless and depressed. It is important for the nurse to provide support and actively listen to a client who makes a statement such as "I wish I could just die." The statement may indicate suicidal ideations. It is also important to document such statements and report them to the health care provider. The nurse should try to explore more about the feelings of the client by asking him or her to tell more about how he or she feels. The nurse should never ignore such statements, because such clients may be suicidal.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. a. Neglecting personal grooming b. Looking at old snapshots of family c. Participating in a senior citizens program d. Visiting the spouse's grave once a month e. Decorating a wall with the spouse's pictures and awards received

b. Looking at old snapshots of family c. Participating in a senior citizens program d. Visiting the spouse's grave once a month e. Decorating a wall with the spouse's pictures and awards received Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms. Note the strategic word, effective, and focus on the subject, effective coping behaviors. Note that options 2, 3, 4, and 5 are comparable or alike and are positive activities in which the individual is engaging to get on with his or her life.

The nurse is teaching a group of nursing students about the facts and myths of old age. Which of the statements below is the best example of a myth of aging? a. Muscle strength decreases with age. b. Older adults are unable to learn new tasks. c. Older adults tend to become victims of crime. d. Older widows tend to adjust better than younger ones.

b. Older adults are unable to learn new tasks. The nurse should be aware of the common myths about older adults. One of them is that older adults are unable to learn new tasks. They only require more time to learn new tasks. Muscle strength does decrease with age. There is a decrease in the number of muscle fibers, and the muscle tissue also becomes atrophied. Older adults tend to lose judgment abilities and thus tend to become victims of crime. Older widows do tend to adjust better than younger ones.

A parent tells the nurse that his or her child often deliberately annoys others and blames others for misbehavior by saying, "They made me do it." What disorder is the child likely to have? a. Intermittent explosive disorder b. Oppositional defiant disorder c. Pyromania d. Kleptomania

b. Oppositional defiant disorder A person with oppositional defiant disorder has a pattern of annoying people and blaming others for his or her behavior. When blaming others, a child may use sentences such as, "They made me do it" or "It's not my fault." Clients with intermittent explosive disorder have aggressive behavior, a delayed consequence of which is remorsefulness. A client with pyromania deliberately sets fires and experiences pleasure as a result. Kleptomania is a repeated failure to resist urges to steal objects.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? a. Paranoid thought process b. Rapid heartbeat or anxiety c. Alcohol withdrawal symptoms d. Thought broadcasting or delusions

b. Rapid heartbeat or anxiety Buspirone is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone most often is indicated for the treatment of anxiety. Note the strategic word, effective. Note the words absence of which manifestation in the question. Recalling that buspirone is an antianxiety medication will direct you to the correct option.

A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? a. Constipation b. Seizure activity c. Increased weight d. Dizziness when getting upright

b. Seizure activity Seizure activity can occur in clients taking bupropion dosages greater than 450 mg daily. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. This medication does not cause significant orthostatic blood pressure changes. Focus on the subject, signs of toxicity associated with bupropion. Note the words excessive amount. These words will direct you to the correct option, the one that identifies the most serious concern.

Depression is the most common and treatable psychiatric condition in the older client. What is the first choice of treatment for depression in this age group? a. Antidepressants b. Social support groups c. Assisted living placement d. Electroconvulsive therapy (ECT)

b. Social support groups Social support groups are the recommended treatment for depression in the elderly, because the cause is usually related to social isolation. Antidepressants may be tried after increasing the client's social network. Assisted living placement is not a treatment and may not address the depression. ECT is reserved for severe depression.

Which behavior would be most characteristic of a client during a manic episode? a. Watching others intently and talking little b. Switching rapidly from one activity to another c. Being unwilling to leave home to see other people d. Taking frequent rest periods and naps during the day

b. Switching rapidly from one activity to another Hyperactivity and distractibility are basic characteristics of manic episodes. Clients experiencing mania tend to talk excessively. Clients with mania are more social than usual. Frequent rest periods are not characteristic of depressive episodes, not manic ones.

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? a. Parkinsonism b. Tardive dyskinesia c. Hypertensive crisis d. Neuroleptic malignant syndrome

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

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? a. Move the client next to the nurses' station. b. Use an indirect light source and turn off the television. c. Keep the television and a soft light on during the night. d. Play soft music during the night, and maintain a well-lit room.

b. Use an indirect light source and turn off the television. Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action. Note the strategic word, initially. Eliminate options that are inappropriate or premature actions and may increase stimulation and add to the confusion. This will direct you to the correct option.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? a. Chess b. Writing c. Board games d. Group exercise

b. Writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them or are group activities and should be avoided because they can stimulate aggression and increase psychomotor activity. Note the strategic words, most appropriate. Eliminate options that include activities that the client cannot do alone and are competitive in nature. The correct option identifies a solitary activity.

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? a. "I don't believe this is true." b. "The guards are not out to kill you." c. "Do you feel afraid that people are trying to hurt you?" d. "What makes you think the guards were sent to hurt you?"

c. "Do you feel afraid that people are trying to hurt you?" It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. Note the strategic word, best. Use therapeutic communication techniques. Eliminate options that show disagreement with the client or encourage any discussion regarding the delusion.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? a. "I swim 3 times a week." b. "I have stopped smoking cigars." c. "I drink hot chocolate before bedtime." d. "I read for 40 minutes before bedtime."

c. "I drink hot chocolate before bedtime." Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. Smoking and alcohol should be avoided. Reading is also a helpful measure and is relaxing. Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Options 1, 2, and 4 are positive statements indicating that the client understands the methods of improving sleep. Remember that chocolate contains caffeine.

The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? a. "My medications will help my anxious feelings." b. "I'll go to support group and talk about what I am feeling." c. "When I have command hallucinations, I'll call a friend for help." d. "I need to get enough sleep and eat well to help prevent feeling anxious."

c. "When I have command hallucinations, I'll call a friend for help." The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt herself or himself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur. Note the strategic words, need for additional information. These words indicate a negative event query and the need to select the incorrect statement as the answer. Focus on the subject, managing hallucinations and anxiety. The correct option is a specific agreement to seek appropriate help. The remaining options are interventions that a client can carry out to aid wellness.

Which individual has the highest risk for major depression? a. 35-year-old married male who recently lost his job b. 6-year-old child who suffers from frequent ear infections c. 55-year-old single female recently diagnosed with rheumatoid arthritis d. 16-year-old male whose family recently moved from one state to another

c. 55-year-old single female recently diagnosed with rheumatoid arthritis The 55-year-old single female has the most risk factors for depression. Primary risk factors include female gender, unmarried, low socioeconomic class, early childhood trauma, a negative life event, family history of depression, ineffective coping ability, postpartum time period, medical illness, absence of social support, and alcohol or substance abuse. The 35-year-old married male, 6-year-old child, and 16-year-old male have fewer risk factors.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? a. A man who has moderate hypertension b. A man who has newly diagnosed cataracts c. A woman who has advanced Parkinson's disease d. A woman who has early diagnosed Lyme disease

c. A woman who has advanced Parkinson's disease lder abuse includes physical, sexual, or psychological abuse; misuse of property; and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least 1 physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care. Focus on the subject, elder abuse. Note the strategic word, most. Read each option carefully and identify the client who is most defenseless as the result of the disease process. This will direct you to the correct option.

A depressive client is prescribed tricyclic antidepressants. What appropriate advice does the nurse give to the client's family? a. Do not give full dose to the client at bedtime. b. Double the dose if the client forgets to take the bedtime dose. c. Advise the client to be cautious while driving. d. Stop the medication if hypotension occurs.

c. Advise the client to be cautious while driving. Tricyclic antidepressants (TCAs) cause side effects such as drowsiness or dizziness. The client must be advised to be cautious while crossing the road, driving, or working with machines. The client must take a full dose at bedtime, so that the side effects are less during the day. If the client forgets to take the dose, the next dose should be taken at the scheduled time. A double dose should be avoided. The medication should not be stopped if there is reduction in blood pressure, because medication cessation can cause nausea, altered heartbeat, cold sweats, and nightmares.

A client says to the nurse, "I once enjoyed going to parks and museums with my family but that is not fun anymore." How would the nurse document this complaint? a. Anergia b. Euthymia c. Anhedonia d. Self-deprecation

c. Anhedonia Anhedonia means that there is no pleasure or joy in life. It is a common finding with depression. Anergia refers to a lack of energy or physical passivity. Euthymia refers to a mood state that is normal and moderate, with neither depression nor mania. Self-deprecation refers to negative statements about self.

A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? a. Client reports not going to work for the past week. b. Client complains of not being able to "do anything" anymore. c. Client arrives at the clinic neat and appropriate in appearance. d. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.

c. Client arrives at the clinic neat and appropriate in appearance. Depressed individuals sleep for long periods, are unable to go to work, and feel as if they cannot "do anything." When these clients have had some therapeutic effect from their medication, they report resolution of many of these complaints and exhibit an improvement in their appearance. Options 1, 2, and 4 identify continued depression. The client's behaviors or reports identified in options 1, 2, and 4 are comparable or alike and are symptoms of depression. The improvement in appearance indicates a therapeutic response to the medication, indicating compliance with the medication regimen.

A client has recently been prescribed an antipsychotropic medication. Which assessment data should the nurse identify as a risk factor for the development of autonomic dysfunction? a. Male b. 23 years of age c. Comorbid diagnosis of depression d. Concomitant use of dantrolene

c. Comorbid diagnosis of depression Risk factors for the development of autonomic dysfunction include older age, female gender (3:2), and presence of a mood disorder. Dantrolene is a medication used as a muscle relaxant and is not considered a risk factor of autonomic dysfunction.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? a. Psychosis b. Repression c. Conversion disorder d. Dissociative disorder

c. Conversion disorder A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Focus on the subject, the cause of acute blindness. The key to the correct option lies in the fact that the client presents no organic reason to account for the blindness—hence, a conversion disorder.

A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. a. Figs b. Yogurt c. Crackers d. Aged cheese e. Tossed salad f. Oatmeal raisin cookies

c. Crackers e. Tossed salad With MAOIs, the client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs. Focus on the subject, acceptable food items while taking MAOIs. Recall that phenelzine is an MAOI and that foods high in tyramine needed to be avoided. Next, from the food items listed in the question, identify the foods that are tyramine-free.

Ageism is best explained as a. Prominent personality disorganization after age 65 years. b. Learned helplessness among elderly clients. c. Discrimination against the elderly on the basis of age. d. Behaviors of elderly persons that serve as barriers to health.

c. Discrimination against the elderly on the basis of age. Ageism is a destructive phenomenon, based on negative attitudes toward the elderly that result in age-related discrimination. Prominent personality disorganization, learned helplessness, and behaviors that serve as barriers to health do not accurately define ageism.

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? a. Place the client in seclusion for 30 minutes. b. Tell the client that the behavior is inappropriate. c. Escort the client to their room, with the assistance of other staff. d. Tell the client that their telephone privileges are revoked for 24 hours.

c. Escort the client to their room, with the assistance of other staff. The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client. Eliminate option 2 because this intervention has already been attempted. Next, use Maslow's Hierarchy of Needs theory to answer the question. Remember that if a physiological need is not present, focus on safety. Look for the option that promotes safety of the client, other clients, and staff.

Which side effects of lithium can be expected when the medication is at therapeutic levels? a. Nausea and thirst b. Ataxia and hypotension c. Fine hand tremors and polyuria d. Coarse hand tremors and gastrointestinal upset

c. Fine hand tremors and polyuria Fine hand tremors and polyuria are present at therapeutic levels of lithium treatment. Nausea and thirst are early signs of toxicity. Ataxia, hypotension, coarse hand tremors and gastrointestinal upset are advanced signs of toxicity.

The client in the dining room states, "I am not eating this food; it tastes like someone has poisoned it." What type of hallucination is this client experiencing? a. Olfactory b. Auditory c. Gustatory d. Visual

c. Gustatory This client is experiencing gustatory hallucinations. Gustatory hallucinations are tasting sensations that are not present in the environment. Olfactory hallucinations involve smelling odors that are not in the environment. Auditory hallucinations entail hearing voices or sounds that do not exist in the environment, but are projections of inner thoughts or feelings. Seeing persons, objects, or animals that are not in the environment is visual hallucination.

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" What does this cognitive distortion represent? a. Self-blame b. Catatonia c. Learned helplessness d. Discounting positive attributes

c. Learned helplessness Learned helplessness results in depression when the client feels no control over the outcome of a situation. Self-blame is an example of negative self-appraisal wherein the client believes that everything is his or her fault. Catatonia is abnormal physical movement. Discounting positive attributes occurs when clients are unable to recognize what they do well.

A 69-year-old client with a recent history of breast cancer is undergoing a workup for memory loss. The client asks "Why am I having all these problems now? I thought life would get easier as I got older." The nurse's response is guided by what knowledge? a. Older people usually have less medical and psychosocial issues than when younger. b. Older adults often exhibit signs of mild depression. c. Older adults experience more medical and psychiatric illnesses. d. Older adults usually adapt to problems easily and have a low risk for suicide.

c. Older adults experience more medical and psychiatric illnesses. Aging is accompanied by increased medical and psychiatric illness. This increase is brought about in part by increasingly stressful life events (e.g., the loss of a spouse, family members, and/or independence) and comorbid illness. Polypharmacy and drug reactions also play a part. There is nothing to indicate that the client is depressed. The elderly population is at high risk for suicide.

A nurse is conducting a survey on the geriatric population in a community. Which observation made by the nurse is appropriate for the geriatric population and can be documented? a. Most older adults are socially isolated and lonely. b. Older adults are unable to learn new tasks. c. Older widows appear to adjust better than younger ones. d. Older adults are more rigid in their thinking and set in their ways.

c. Older widows appear to adjust better than younger ones. Research suggests that older widows appear to adjust better than younger ones. The client tries to cope with the situation and adjusts according to the present situation. That older adults are socially isolated and lonely is a myth. They are not isolated, but some elderly clients may be neglected by their children who make them feel lonely, and the older clients in turn get depressed. That older adults are unable to learn new tasks is a myth. A person with interest and zeal to learn can perform any task. Clients must be encouraged to perform tasks that enhance confidence. That older adults are more rigid in their thinking and set in their ways is a myth.

What disorder is best described by an uninterrupted period of illness during which there is a major depressive, manic, or mixed episode, concurrent with symptoms that meet the criteria for schizophrenia? a. Delusional disorder b. Schizophreniform disorder c. Schizoaffective disorder d. Substance-induced psychotic disorder

c. Schizoaffective disorder Schizoaffective disorder is best described by an uninterrupted period of illness during which there is a major depressive, manic, or mixed episode, concurrent with symptoms that meet the criteria for schizophrenia. Delusional disorder involves nonbizarre delusions for at least one month. Schizophreniform disorder has the essential features that are exactly the same as those of schizophrenia. Substance-induced psychotic disorder is caused by the ingestion of or withdrawal from a substance.

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? a. Ask direct questions to encourage talking. b. Leave the client alone so as to minimize external stimuli. c. Sit beside the client in silence with simple open-ended questions. d. Take the client into the dayroom with other clients to provide stimulation.

c. Sit beside the client in silence with simple open-ended questions. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients. Note the strategic words, most appropriate. Eliminate options either that are nontherapeutic or could result in overstimulation. Also eliminate options that are not examples of therapeutic communication. The correct option provides for client supervision and communication as appropriate.

Which statement is true of the relationship between bipolar disorder and suicide? a. Clients with bipolar disorder are not considered to be at a high risk for suicide. b. Clients need to be monitored only in the depressed phase, because this is when suicides occur. c. Suicide is a serious risk, because nearly 20% of those diagnosed with bipolar disorder commit suicide. d. As long as clients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.

c. Suicide is a serious risk, because nearly 20% of those diagnosed with bipolar disorder commit suicide. Mortality rates for bipolar disorder are severe because 25% to 50% of individuals with bipolar disorder will make a suicide attempt at least once in their lifetimes, and the suicide rate of bipolar individuals is 15% to 20%. Suicides occur in both the depressed and the manic phases. Bipolar clients are always considered high risk for suicide because of their impulsivity while in the manic phase and hopelessness when in the depressed phase. Although staying on medications may decrease risk, there is no evidence to suggest that only clients who stop medications commit suicide.

A nurse is performing a clinical assessment of an elderly client. What appropriate techniques should the nurse follow while interacting with the client? a. The nurse should stand and allow the client to sit on the chair. b. The nurse should conduct the interview in a dimly lit room. c. The nurse should conduct the interview in a closed room. d. The nurse should use the client's first name when addressing him or her.

c. The nurse should conduct the interview in a closed room. The nurse should conduct the interview in a closed room or in a private area of the hospital. This encourages the client to discuss openly with the nurse. The nurse can establish rapport and put the client at ease by sitting or standing at the same level as the client. Adequate lighting and reduced noise levels must be maintained in the interview room. This helps the client to see and hear well. The nurse should ask the client what the client would like to be called. Always addressing the client with his or her first name is not appropriate unless the client recommends doing so.

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What should the nurse tell the AP about older clients with hearing loss? a. They are often distracted. b. They have middle ear changes. c. They respond to low-pitched tones. d. They develop moist cerumen production.

c. They respond to low-pitched tones. Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging. Focus on the subject, age-related changes related to hearing. Think about the physiological changes associated with aging. Recalling that the client with a hearing loss responds to low-pitched tones will direct you to the correct option.

What population is most at risk for schizophrenia spectrum disorders? a. Middle age adults b. Older adults c. Young adults d. Toddlers

c. Young adults The schizophrenia spectrum disorders are devastating brain diseases that target young people in their teens or early twenties at the beginning of their productive lives. Middle age and older adults are less at risk. It is rarely evidenced in childhood.

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? a. Encouraging quiet reading and writing for the first few days b. Identification of physical activities that will provide exercise c. No socializing activities until the client asks to participate in milieu d. A structured program of activities in which the client can participate

d. A structured program of activities in which the client can participate A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation. Focus on the subject, the plan for a client with depression. Recall that a depressed client requires a structured and stimulating program in a safe environment. The correct option is the only one that will provide a safe and effective environment.

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? a. Planning meals b. Decorating the room c. Scheduling haircut appointments d. Allowing the client to choose social activities

d. Allowing the client to choose social activities Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the only one that allows the client to be a decision maker. Focus on the subject, encouraging autonomy. Recalling the definition of autonomy will direct you to the correct option. Remember that giving the client choices is essential to promote independence.

A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? a. Take the medication only with meals. b. Take the medication at the same time each day. c. Use a dose container to help prevent missed doses. d. Avoid drinking alcohol while taking this medication.

d. Avoid drinking alcohol while taking this medication. Phenobarbital is an anticonvulsant and hypnotic agent. The client should avoid taking any other central nervous system depressants such as alcohol while taking this medication. The medication may be given without regard to meals. Taking the medication at the same time each day enhances compliance and maintains more stable blood levels of the medication. Using a dose container or "pillbox" may be helpful for some clients. Focus on the subject, client safety, and note the strategic words, highest priority. Eliminate option 1 because of the closed-ended wordonly. Although options 2 and 3 are correct teaching points, these are not the highest priority from the options provided. Remember that alcohol should not be consumed when a hypnotic is taken because of its adverse effects.

Which is an advanced but not severe sign of lithium toxicity? a. Sedation b. Polyuria c. Mild thirst d. Blurred vision

d. Blurred vision Sedation is an advanced sign of lithium toxicity when the blood plasma level of lithium is 1.5-2.0 mEq/L. Polyuria is an early sign of lithium toxicity when the blood plasma level of lithium is 1.5 mEq/L. Mild thirst is an expected side effect of lithium when the blood plasma level of lithium is 0.4-1.0 mEq/L. Blurred vision usually occurs when lithium toxicity is severe and blood levels are 2.0-2.5 mEq/L.

A terminally ill, elderly client wants to ensure that his or her wishes about end-of-life care are followed. To best guarantee this, what should the client do? a. Remain in control of health care decision making b. Write a living will c. Issue a directive to his or her health care provider d. Execute a durable power of attorney for health care

d. Execute a durable power of attorney for health care With a durable power of attorney for health care, an individual designates a health care proxy who is informed of the client's wishes and is empowered to act on his or her behalf. No waiting period is required for the document to take effect. Remaining in control of health care decision making, writing a living will, or issuing a directive to his or her health care provider does not provide a guarantee to the client.

A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? a. Complaints of insomnia b. Complaints of hunger and fatigue c. A pulse rate less than 60 beats per minute d. Frequent hand washing with hot, soapy water

d. Frequent hand washing with hot, soapy water Clomipramine is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Sedation sometimes occurs. Insomnia seldom is a side effect. Weight gain and tachycardia are side and adverse effects of this medication. Focus on the subject, noncompliance with clomipramine. Recalling that this medication is a tricyclic antidepressant used to treat obsessive-compulsive disorder will direct you to the correct option.

The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? a. Get adequate sunlight. b. Continue driving as usual. c. Avoid foods rich in potassium. d. Get up slowly when changing positions.

d. Get up slowly when changing positions. Risperidone can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. With any psychotropic medication, caution needs to be taken (such as with driving or other activities requiring alertness) until the individual can determine whether her or his level of alertness is affected. Food interaction is not a concern. Focus on the subject, parameters to monitor for the client taking risperidone. It is necessary to know the nursing considerations related to the administration of risperidone and that risperidone can cause orthostatic hypotension. Also, use of the ABCs—airway, breathing, circulation—will direct you to the correct option.

The nurse is performing a clinical assessment of an elderly client with acute renal failure. The nurse finds that the client appears confused and is likely to have delirium. Which factor should the nurse assess in the client to find the cause for the delirium? a. Hygiene b. Social isolation c. Nutrition imbalance d. Medications

d. Medications In elderly clients, delirium is assumed to be caused due to age. The nurse should assess whether the client has delirium due to age, adverse drug reaction, or changes in physiology. Elderly clients usually take many drugs at a time and may develop delirium due to an adverse drug interaction. Assessment of hygiene will not help identify the cause of delirium. Social isolation is used to assess depression and may not help in assessment of delirium. Assessment of nutritional imbalance does not help in assessment for delirium. It can be assessed in clients who are neglected and have financial constraints.

According to Touhy's classification of the elderly over the age of 65, who are called elite-old according to this classification? a. People aged 65 to 74 years b. People aged 75 to 84 years c. People aged 85 to 94 years d. People older than 94 years

d. People older than 94 years Touhy has given a common classification for people aged 65 years and above. According to this classification, those over 94 years are called elite-old. People aged 65 to 74 years are young-old, those between 75 and 84 years are middle-old, and old-old are people between 85 and 94 years.

The nurse cares for an adult who repeatedly says, "My dead relatives try to talk to me and penetrate my body." This comment is most associated with which disorder? a. Seasonal affective disorder b. Substance-induced depressive disorder c. Disruptive mood dysregulation disorder d. Psychotic depression

d. Psychotic depression Depressive disorders are classified according to symptoms or the situations under which they occur. Delusional thinking is an aspect of psychosis that may be present in cases of psychotic depression. Seasonal affective disorder is characterized by marked seasonal differences in mood associated with decreased daylight. Substance-induced depressive disorder applies when symptoms of a major depressive episode arise associated with drug or alcohol intoxication or withdrawal. Disruptive mood dysregulation disorder relates to children and refers to situations in which a person has frequent temper tantrums, resulting in verbal or behavioral outbursts out of proportion to the situation.

What are the most useful group therapy modalities for the older client? a. Adult day care and reminiscence therapy b. Extended care facility and psychotherapy c. Reminiscence and general support groups d. Re-motivation therapy and psychotherapy

d. Re-motivation therapy and psychotherapy Re-motivation therapy and psychotherapy are group therapy modalities that help address the needs of the older client. Re-motivation therapy helps to reawaken interest in the environment and re-socialize apathetic clients. Psychotherapy helps to alleviate psychiatric symptoms and increase the ability to interact with others in a group setting. Adult day care is for the older client who is not safe to be alone and needs supervision. Extended care facilities are for older clients needing an increased level of supervision and care to remain safe. A general support group would not have the focus needed for the older client.

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? a. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." b. Suggest to the client and daughter-in-law that they consider a nursing home for the client. c. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. d. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

d. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center. Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes it necessary for the nurse to intervene legally and ethically, so option 3 is not appropriate and is passive in terms of advocacy. Option 2 suggests committing the client to a nursing home and is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of the nursing care required. Option 1 is incorrect and judgmental.

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? a. Platelet count b. Blood glucose level c. Liver function studies d. White blood cell count

d. White blood cell count A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication. Focus on the subject, complications associated with clozapine. It is necessary to recall that this medication causes agranulocytosis; this will direct you to the correct option.