Psych CBA 2 (updated)
A nurse working on a geropsychiatric unit designs new clinical protocols. Which potential problems have the highest priority? a. Risks for falls b. Cognitive errors c. Memory deficits d. Nutritional deficits
A Patients in geropsychiatric units have an especially high risk for falls. Safety is the nurse's priority concern.
Which neurotransmitter is most affected by an anticholinergic drug? a. Acetylcholine b. Dopamine c. Serotonin d. GABA
A Anticholinergic drugs inhibit acetylcholine, thereby preventing stimulation of the cholinergic excitatory pathways. The other neurotransmitters are associated with the etiology of schizophrenia, anxiety, and depression.
A patient's areas of strength are documented in which part of the plan of care? a. Assessment b. Diagnosis c. Outcome identification d. Interventions e. Evaluation
A Areas of strength are part of the nurse's assessment, and documentation is appropriate only in that part of the plan of care. This information is very important for the later steps of outcome identification and planning.
Which third-generation antipsychotic medication acts by stabilizing the dopamine system? a. Aripiprazole b. Ziprasicone c. Quetiapine d. Risperidone
A Aripiprazole is novel in action. It acts by stabilizing the dopamine system through partial agonism of dopamine D2 and 5-HT2. The other drugs are atypical antipsychotics, which have other modes of action that produce therapeutic effects.
Which type of perceptual alteration is most commonly displayed by patients with schizophrenia? a. Auditory hallucinations b. Inappropriate affect c. Loose associations d. Illusions
A Auditory hallucinations are the most commonly experienced perceptual alteration noted in schizophrenia. Illusions are less common. The other symptoms are not altered perceptions.
Which therapeutic intervention should the nurse suggest for a patient with panic attacks and problems with concentration? a. Occupational therapy b. Medication education c. Recreational therapy d. Group therapy
A Occupational therapists prescribe activities that can help the patient increase concentration and focus. The other activities are not designed to increase concentration and attention span.
During a psychiatric emergency, a patient is given a traditional antipsychotic drug intramuscularly and placed in seclusion. Over the next 2 hours, which aspect of physical assessment is most important? a. Blood pressure, pulse, and respirations b. Urinary output c. Abnormal involuntary movements (AIMS scale) d. Temperature
A A traditional antipsychotic medication administered intramuscularly might produce the marked antiadrenergic side effect of hypotension, thus making blood pressure an important assessment. It may also precipitate cardiac arrhythmias, so monitoring pulse and respirations is important. Decreased urinary output is related to anticholinergic side effects and would not be a priority assessment during the first 2 hours. The AIMS scale assesses for tardive dyskinesia, a late complication of antipsychotic therapy. Temperature assessment is relevant if assessing for neuroleptic malignant syndrome, a complication that develops after several doses of antipsychotic medication.
A patient has taken perphenazine for a year. The nurse observes lip smacking and grinding teeth. Which tool should the nurse use to complete the client's assessment? a. AIMS b. EPSE c. SAD PERSONS d. CAGE
A AIMS is the Abnormal Involuntary Movement Scale. It was developed to screen for tardive dyskinesia. EPSE refers to extrapyramidal side effects. The other tools are for assessing alcohol abuse and suicidality.
The nurse should focus assessment for a patient with type I schizophrenia primarily on gathering data about what patient characteristic? a. Cognition and perception b. Attention and motivation c. Grooming and hygiene d. Abstract thinking skills
A Altered perception includes hallucinations, illusions, and paranoid thinking. These positive symptoms, along with abnormal thoughts, are hallmarks of type I schizophrenia. The other options are more often seen in patients with type II schizophrenia.
A nurse reads this information in a patient's record: suffered anoxia at birth; foster home placement at age 3; taunted by peers during childhood; low self-esteem since adolescence. Which item would be classified as a biologic factor associated with the patient's mental illness? a. Anoxia at birth b. Low self-esteem c. Taunted by peers d. Trauma caused by parental death
A Biologic causes arise from nature; that is, they are organic or genetic. Anoxia is an organic etiology. The other conditions are of psychological etiology.
A novice nurse asks, "What is the role of psychopharmacology in the psychotherapeutic management model?" What response should the mentor provide concerning the role of psychopharmacology? a. Making it possible to use the least restrictive treatment alternatives. b. Preventing violence against nurses and family members. c. Assisting in the identification and achievement of desirable outcomes. d. Facilitating in the determination of the responsible psychopathology.
A By effectively treating psychotic symptoms, the incidence of violent behaviors has been reduced. This makes possible the use of the least restrictive treatment alternative, an important facet of psychotherapeutic management. Psychopharmacology does not make the other options possible.
When developing a teaching plan for a patient receiving benztropine, what is a priority nursing consideration? a. Anticholinergic drugs often cause blurred vision. b. Urinary frequency may impair the patient's concentration. c. Akathisia produced by the drug will make concentration difficult. d. Increased peristalsis might cause gastrointestinal distress and impair concentration.
A CNS effects include confusion, drowsiness, and decreased memory and learning. This might affect the patient's ability to learn. Anticholinergics do not cause urinary frequency, akathisia, or increased peristalsis.
A patient diagnosed with schizophrenia expresses fear of being pursued by hostile forces. The patient carries a tablet and writes notes in a code. The patient says, "I'm the only one who understands this code." How should the nurse document these findings? a. Grandiose and paranoid delusions b. Affective blunting and anhedonia c. Autism and loose associations d. Delusions of reference
A Delusions are fixed false beliefs. Paranoid delusions reflect the idea that the person is being persecuted. Grandiose delusions are characterized by the idea that one is of great importance. The scenario does not describe any of the behaviors that would be consistent with the other options.
When a patient experiencing a first episode of type I schizophrenia is hospitalized, the nurse can expect to administer what type of medication? a. A typical antipsychotic drug b. An atypical antipsychotic drug c. A mood-stabilizing anticonvulsant d. A selective serotonin reuptake inhibitor
A Delusions, hallucinations, and other symptoms of type I schizophrenia usually respond to the typical antipsychotic medications. Positive symptoms are considered to be the result of a subcortical dopaminergic process. The typical antipsychotics are dopamine blockers.
Which patient diagnosed with schizophrenia and receiving antipsychotic medication should receive the nurse's priority attention based on presenting characteristics? a. The one assessed with diaphoresis and a temperature of 104°F b. The one reporting feelings of neck and shoulder stiffness c. The one reporting auditory hallucinations of loudly clanging church bells d. The who chanting, "I am the messiah, delivered to earth from the heavens above"
A Diaporesis and fever are findings indicating neuroleptic malignant syndrome (NMS), a serious adverse reaction to antipsychotic medication. The other findings may be significant but are a lesser priority.
The nurse caring for a patient receiving a dopaminergic drug should assess the individual for early symptoms of what schizophrenia-associated condition? a. Psychosis b. Fluid imbalance c. Tardive dyskinesia d. Labile hypertension
A Dopamine excess is associated with schizophrenia. When dopaminergic drugs are given, symptoms of psychosis might appear or be exacerbated. Tardive dyskinesia is associated with dopamine deficiency. The other options are unrelated to the medication or to schizophrenia.
When assessing for a positive outcome to drug therapy with fluphenazine, the nurse would look primarily for improvement in which focus area? a. Hallucinations b. Range of affect c. Personal hygiene d. Social interactions
A Fluphenazine, a typical antipsychotic, will produce improvement in the positive symptoms associated with schizophrenia, such as hallucinations. Less improvement is expected in negative symptoms such as affect, activity, and grooming.
Which argument effectively supports the importance of funding services for persons with mental illness in the United States? a. During any given year 25% of adult Americans are affected by mental disorders. b. Increasing toxins in the environment are increasing the incidence of mental illness. c. The high prevalence of mental illness is directly linked to increasing violence in the media. d. The incidence of mental illness is increasing because of deterioration of the American family.
A Funding is justified based on the high incidence of mental illness. The origins of mental illness are multifaceted. It is overly simplistic to associate these problems with one or two variables.
Which adjective best describes a therapeutic psychiatric nurse? a. Holistic b. Organized c. Diplomatic d. Compassionate
A Holism is crucial to knowledgeable, safe, and effective practice as a psychiatric nurse. The distracters are incomplete. Compassion is an aspect of holism.
A nurse assesses a newly hospitalized patient with a long history of serious and persistent mental illness. What is the priority assessment information should the nurse obtain to minimize any risk associated with medication safety? a. Adverse reactions to drugs taken previously b. History of drug compliance and noncompliance c. Level of support available from significant others d. Length of time on various psychotropic medic
A Information related to safety is the nurse's priority. Adverse reactions to psychotropic medications can be dangerous, even life-threatening. If a patient has had an adverse reaction to a particular drug, it would be unwise to administer it again. The other options do not address a safety issue.
When a patient is taking a traditional antipsychotic medication, the nurse should assess carefully for which common extrapyramidal (EPSE) side effect? a. Akathisia b. Mydriasis c. Hypotension d. Constipation
A It is estimated that more than 25% of all patients receiving antipsychotic medication experience akathisia, a subjective feeling of restlessness and jitteriness and a desire to stand or walk. Akathisia typically manifests itself early in treatment. The other options are not considered EPSEs.
19. Which therapeutic activity would be most important in helping a patient diagnosed with schizophrenia remain in the work force? a. Social skills training b. Physical therapy to develop muscle strength c. Occupational therapy to improve coordination d. Group therapy to improve motivation for working
A Patients with schizophrenia often cannot obtain and hold jobs, not from lack of work skills but from inability to cope socially on the job. Social skills training would therefore be of greatest assistance if work skills are present. This premise is especially true for an individual with residual schizophrenia, since active psychosis is no longer present.
How do prevalence rates for substance abuse disorders in the United States currently present? a. Higher for men b. Higher for women c. Equal for both genders d. Higher than anxiety disorders
A Prevalence rates for substance abuse disorders are highest in men. The remaining options are not true regarding substance abuse prevalence.
Studies demonstrate the need to focus on what nursing diagnosis to support the psychiatric patients' understanding of psychopharmacology? a. Deficient knowledge related to drug therapy b. Impaired memory related to drug side effects c. Impaired decision-making related to drug dependency d. Disturbed thought processes related to anticipation of side effects
A Research has shown that most patients do not know important facts about the medications prescribed for them. As a result, they are often noncompliant. As knowledge deficits are removed, better compliance can be expected. Data are not present to suggest applicability of the other options.
A nurse at the mental health clinic plans a series of psychoeducational groups for persons with schizophrenia. Which topic would take priority? a. The importance of taking your medication correctly b. How to complete an application for employment c. How to dress when attending community events d. How to give and receive compliments
A Stabilization is maximized by adherence to the antipsychotic medication regime. The other topics are also important, but are not priority topics.
6. What general psychotherapeutic management guideline should nurses apply when caring for all patients? a. Strengthen patients' self-esteem. b. Keep reality testing to a minimum. c. Ignore hostile behavior when possible. d. Provide unrestricted opportunities for self-expression.
A Strengthening patients' self-esteem is an important aspect of psychotherapeutic management and a key part of the nurse's role. The distracters are not always therapeutic.
Which diagnosis meets criteria for admission to a co-occurring inpatient unit? a. Bipolar disorder, manic phase, patient has abused alcohol daily to self-medicate b. Undifferentiated schizophrenia and hallucinations of angels playing harps c. Major depression, suicidal intent, and a highly lethal suicide plan d. Anorexia nervosa and 30% underweight
A The patient experiencing a bipolar episode and abusing alcohol would meet criteria for such a diagnosis unit, since its focus is on the treatment of substance abuse and mental illness in a psychiatric hospital setting. The other three patients require acute psychiatric care but do not meet the admitting criteria.
A patient who is receiving an antipsychotic drug is restless, paces, and cannot sit still when watching television. The patient says, "I couldn't sleep last night because I needed to pace." What is the expected intervention by the patient's primary health care provider? a. A prescription for an anticholinergic drug b. Discontinuation of the antipsychotic drug c. A prescription for a dopaminergic medication. d. A prescription for a bedtime antihistamine to promote sleep.
A The patient's motor symptoms can be assessed as akathisia. Anticholinergic medication provides relief for some patients. The nurse should report the patient's symptoms to the health care provider and anticipate the order to begin anticholinergic therapy. The other options do not provide acceptable alternatives.
Research on neurostructural theories of schizophrenia indicates the common demonstration of which pathoanatomic findings? a. Ventricular enlargement, brain atrophy, and diminished cerebral blood flow b. Ventricular blocking, brain swelling, and enhanced cerebral blood flow c. Decreased cortical thickness and hippocampal hyperplasia d. Increased cortical thickness and temporal lobe scarring
A Theorists have suggested that type II schizophrenia is the result of pathoanatomy, specifically increased ventricular brain ratios, brain atrophy, and decreased cerebral blood flow. The other alterations are not supported by research findings.
A patient has taken a traditional antipsychotic medication for several years is now demonstrating involuntary tongue movements and lip smacking. What should be the nurse's initial action? a. Notifying the health care provider b. Administering PRN doses of an anticholinergic drug c. Implementing behavioral modification techniques to help the patient manage these motions. d. Counseling the patient about the social ramifications of these movements by others.
A These symptoms suggest the presence of tardive dyskinesia and should be reported to the health care provider, who will probably discontinue the drug or change to an atypical drug. The movements are involuntary so behavioral modification would not be effective and counseling would not be directed to this aspect of the problem. Tardive dyskinesia does not respond to anticholinergics.
A nurse reviews laboratory reports for a patient who has taken clozapine for 1 year. Which WBC and granulocyte values would prompt the nurse to notify the health care provider of the need to suspend treatment? a. 2900 cells/mm3 and 1450 cells/mm3. b. 3500 cells/mm3 and 1850 cells/mm3. c. 4000 cells/mm3 and 2000 cells/mm3. d. 4500 cells/mm3 and 2500 cells/mm3.
A These values indicate that leukopenia is present. Agranulocytosis is a sometimes fatal side effect of clozapine. The other values are above baseline.
How long must the symptoms of schizophrenia be present before a diagnosis can be made? a. At least 6 months b. At least 1 month c. More than 1 week d. On at least three occasions in the past year
A To meet diagnostic criteria, signs of schizophrenia must be continuously present for a minimum of 6 months and not caused by substance abuse or a medical disorder.
60-year-old female patient who has taken traditional antipsychotic medication for 20 years should be screened for which potential side effect? a. Osteoporosis b.Metabolic syndrome c. Polycystic ovary disease d. Neuroleptic malignant syndrome (NMS)
A Traditional antipsychotic medications increase prolactin levels, placing patients at risk for development of osteoporosis. Atypical antipsychotics increase the risk for metabolic syndrome. Screening for NMS and polycystic ovary disease are not indicated.
Which information should the nurse include in the teaching plan for a patient receiving clozapine? a. "Abstain from using tobacco products." b. "Increase your daily carbohydrate intake." c. "Notify your health care provider if you start drooling." d. "You will need monthly electrocardiographic tracings done."
A Use of tobacco products speeds metabolism of clozapine in the liver, reducing the clozapine level and diminishing its effectiveness in reducing symptoms. Increasing carbohydrate intake is contraindicated because of the possibility of developing metabolic syndrome. Drooling is a common side effect. Monthly electrocardiographic tracings are unnecessary, but annual or semiannual tracings might be suggested, because arrhythmia development is possible.
A patient diagnosed with schizophrenia has experienced good symptom control through medication therapy. Today, the patient is admitted with paranoia and auditory hallucinations. The nurse should initially determine if the patient's symptoms are related to which possible trigger? a. Not taking the drug as prescribed b. Activation of serotonin receptors c. Development of tolerance to the drug d. An expected illness-exacerbation cycle
A When a patient does not respond to a drug, or when symptoms reappear after a good response to the drug, the nurse should assess for compliance. Is the patient taking the drug? Is the patient taking less of the drug than ordered? The other options are less relevant or of no value to the development of the stated symptoms.
A patient who takes a traditional antipsychotic medication says, "I feel shaky and very warm." The patient is diaphoretic. What is the nurse's best first action when suspecting that a patient is experiencing neuroleptic malignant syndrome (NMS)? a. Take the patient's vital signs. b. Position the patient in the semi-Fowler position. c. Begin oxygen by nasal cannula at 2 L/min. d. Place the patient on one-to-one supervision.
A When signs and symptoms suggest that the patient might be experiencing NMS, the first action would be to check vital signs. NMS produces elevated temperature, blood pressure fluctuations, and irregular heart rate in addition to muscle rigidity and altered levels of consciousness. None of the other options address the assessment needs of such a patient.
A patient takes a psychotropic medication that affects serotonin receptors. The patient complains of anxiety, insomnia, and loss of appetite. What effect is the drug having on the serotonin receptors? a. Activation b. Antagonism c. Paradoxical d. Inhibition
A The patient's reports indicate activation of serotonin receptors. None of the other options correctly identifies this effect.
2. An outpatient diagnosed with schizophrenia has been omitting doses of medication. Which questions should the clinic nurse ask to determine the reasons for the problem? (Select all that apply.) a. "Are you experiencing any troublesome side effects?" b. "Is the medicine affecting your sexual performance?" c. "Does the medicine make you think slower?" d. "Do you believe your dose is too low?" e. "Do you believe you have an illness?"
A, B, C, E The correct options refer to a common reason for patients not taking medication as prescribed. Usually a patient will stop taking prescribed medications if they belief that the dose is too high rather than too low.
A patient diagnosed with Parkinson disease begins levodopa therapy. What outcome should the nurse expect from levodopa therapy? (Select all that apply.) a. Improvement of associated symptoms related to the increase of dopamine b. Improvement of associated symptoms related to the decrease levels of GABA c. Reduction of any existing depression d. Reduction in the risk of dysphagia e. Reduction in the risk of falls associated with an unsteady gait
A, C, D, E Levodopa is converted to dopamine in the central nervous system (CNS), so its administration will cause a reduction in the symptoms of Parkinson disease related to dopamine deficiency. Levodopa increases dopamine levels. Levodopa will improve the patient's swallowing ability and gait, and will reduce symptoms of depression. Levodopa is not associated with changes in gamma-aminobutyric acid (GABA).
A patient prescribed which medication should be counseled about the drug's tendency to cause weight gain? (Select all that apply.) a. Olanzapine b. Dantrolene c. Benztropine d. Chlorpromazine e. Ziprasidone
A, D Olanzapine and chlorpromazine cause considerable weight gain in some patients. None of the remaining options are associated with weight gain.
Patient teaching for individuals taking risperidone should include what interventions? (Select all that apply.) a. Measures to prevent episodes of orthostatic hypotension b. Strategies to maintain fluid and electrolyte balance c. Information on the importance of monthly WBC count monitoring d. Dietary management to avoid weight gain e. Self-monitoring for facial tics
A, D Risperidone causes orthostatic hypotension, sedation, and appetite stimulation. When taken in moderate doses, its favorable side effect profile suggests that teaching regarding extrapyramidal side effects (EPSEs) and tardive dyskinesia can be minimal. Fluid and electrolyte imbalance and agranulocytosis are not usual side effects.
When comparing major differences between traditional and atypical antipsychotic drugs, which statements are correct? (Select all that apply.) a. Traditional antipsychotic drugs produce more EPSEs. b. Traditional antipsychotic drugs are more likely to produce weight gain. c. Traditional antipsychotic drugs alter dopamine and serotonin transmission. d. Atypical medications have a greater therapeutic effect on both positive and negative symptoms. e. Atypical medications are more likely to cause tardive dyskinesia.
A, D Traditional antipsychotics have a higher incidence of EPSEs and tardive dyskinesia. Atypical antipsychotics are more likely to produce weight gain and alter dopamine and serotonin transmission.
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who says he is becoming more anxious during group therapy D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months
A. A client in acute care who has been running and falling should be helped by the treatment team on her unit. B. CORRECT: An ACT group works with clients who are nonadherent with traditional therapy, such as the client in a home setting who keeps "forgetting" his injection. C. A client who has anxiety might be referred to his counselor or mental health provider. D. A client who is grieving for her husband who died 3 months ago is currently involved in an appropriate intervention.
A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply.) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy
A. CORRECT: Educational groups are services provided in a community mental health facility. B. CORRECT: Medication dispensing programs are services provided in a community mental health facility. C. CORRECT: Individual counseling programs are services provided in a community mental health facility. D. Detoxification programs are services provided in a partial hospitalization program. E. CORRECT: Family therapy is a service provided in a community mental health facility
A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following strategies should the nurse suggest as appropriate follow‑up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis
A. Daily care provided by a home health aide will not provide adequate supervision for this client. B. Weekly visits from a case worker will not provide adequate care and supervision for this client. C. CORRECT: A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present. D. Daily visits to a community mental health center will not provide consistent supervision for this client.
A nurse is caring for several clients who are attending community‑based mental health programs. Which of the following clients should the nurse plan to visit first? A. A client who recently burned her arm while using a hot iron at home B. A client who requests that her antipsychotic medication be changed due to some new adverse effects C. A client who says he is hearing a voice that tells him he is not worthy of living anymore D. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview
A. T his client has needs that should be met, but there is another client whom the nurse should see first. B. T his client has needs that should be met, but there is another client whom the nurse should see first. C. CORRECT: A client who hears a voice telling him he is not worthy is at greatest risk for self‑harm, and the nurse should visit this client first. D. T his client has needs that should be met, but there is another client whom the nurse should see first.
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression
A. T his intervention is an example of primary prevention. B. T his intervention is an example of secondary prevention. C. CORRECT: Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness. D. T his intervention is an example of primary prevention.
Which treatment setting would necessitate the most restrictive environment? a. Partial hospitalization b. Geropsychiatric unit c. Forensic hospital d. Group home
C Patients in forensic hospitals have mental illness as well as conviction or charges for criminal activity. These settings must be therapeutic but also confine patients from society. Rules, regulations, and restrictions have similarities to those of prisons.
9. An older adult patient diagnosed with delirium is anxious, agitated, and experiencing visual hallucinations. The nurse entering the room to assess vital signs should implement which intervention to best address this behavior? a. Calmly announce yourself by name and title, and explain what is going to happening. b. Limit talking with the client while taking the vital signs to minimize stimulation. c. Ask the patient to identify place, person, and time to trigger memory. d. Turn on all lights in the room to minimize misinterpretation of events.
ANS: A A patient who is anxious, confused, and experiencing sensory perceptual alterations needs help coping with the environment. Nurses should identify themselves whenever entering the room, giving both their name and title, and provide simple explanations and directives. The other options are inadvisable since they do not address the patient's anxiety level.
Which intervention is an example of a complementary and alternative medicine therapy? a. Acupuncture b. Bright-light therapy c. Electroconvulsive therapy d. Repetitive transcranial magnetic stimulation
ANS: A Acupuncture is considered a complementary and alternative therapy. The other therapies are accepted by Western medicine.
13. After a mass transit disaster many injured patients are expected at the emergency room. The nurse prepares to plan interventions for which likely mental health assessment findings? a. Dissociative symptoms, numbing, detachment, and derealization b. Auditory hallucinations and other perceptual distortions including paranoia c. Somatic neurologic disorders and amnesia d. Exaggerated mood including both depression and manic-related elation
ANS: A Acute stress reactions are marked by dissociative symptoms such as numbing of emotional responsiveness, feelings of detachment, and decreased awareness of surroundings. The other options list behaviors that are atypical of acute stress reactions.
6. A pregnant patient experiencing insomnia reports taking diazepam and wine in increasing amounts to be able to sleep. The nurse should teach the patient about what risk associated with this habit? a. Central nervous system (CNS) depression b. Acetaldehyde toxicity c. Fetal alcohol syndrome d. Miscarriage
ANS: A Alcohol ingested with another CNS depressant can produce lethal depressant effects. The other options are not relevant based on the information given in the scenario nor the effects of combining the medication and alcohol.
27. Which characteristic of an inpatient unit organizational culture predisposes the highest risk for patient violence and aggression? a. Staff member behavior authoritarian b. High degree of structural flexibility c. Feeling of safety among patients d. Bland colors used in decor
ANS: A An important variable affecting the risk of aggression is staff attitude. A higher risk for assault is present for staff with authoritarian attitudes. Such attitudes demean patients, who might act out in anger or defense against feeling depersonalized and powerless.
20. A newly admitted patient diagnosed with Alzheimer disease (AD) has demonstrated apraxia. The nurse should assist the patient with which activity? a. Grooming and hygiene b. Reading written material c. Word finding d. Orientation
ANS: A Apraxia is the inability to carry out motor activities despite intact motor function. The patient activity that would be altered by lack of motor function is grooming and hygiene. None of the other options are related to motor activities.
12. A nursing assistant reports to the nurse that a patient diagnosed with Alzheimer disease (AD) is experiencing severe diarrhea. Administration of which classification of medication is most associated with this problem? a. ChE inhibitor b. Secretase inhibitor c. NDMA antagonist d. Nonsteroidal antiinflammatory drug
ANS: A ChE inhibitors used in treatment of AD increase the availability of ACh, which stimulates action of the parasympathetic nervous system. This stimulation is likely to produce diarrhea. The other classifications work by different actions.
2. A nurse assesses a newly admitted patient with possible delirium. Which aspect of the history provides by family members contributes to confirmation of the diagnosis? a. "He became confused all of a sudden." b. "He is always conscious and alert." c. "He doesn't seem to understand jokes anymore." d. "He is so distrustful of everyone now."
ANS: A Delirium develops rapidly, as opposed to dementia, which has an insidious onset. Other symptoms of delirium include fluctuating level of consciousness, logical thoughts alternating with illogical thoughts, presence of visual hallucinations, and day-night sleep reversal. Loss of ability to abstract is also seen in dementia. Paranoid delusions are common to dementia.
7. An older adult presents with symptoms of delirium. The family says, "Everything was fine until yesterday." What is the most important assessment information the nurse should gather? a. A list of medications the patient currently takes. b. Whether or not the patient has experienced any recent losses. c. Whether or not the patient has ingested aged or fermented foods. d. The patient's recent personality characteristics and changes.
ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to monoamine oxidase inhibitor therapy and pseudodementia.
4. What is the most realistic short-term goal for the care of a patient with mild Alzheimer disease (AD) who takes donepezil? a. To maintain present cognitive ability b. To show improved cognitive ability c. To engage effectively in abstract thinking d. To consistently communicate clearly
ANS: A Donepezil can be expected to inhibit cholinesterase (ChE), increasing the amount of intrasynaptic ACh. This drug does not cure AD, nor will it stop its eventual progression. For the present it should, however, preserve the patient's level of cognitive function.
17. A patient has entered the escalation phase of the assault cycle. Select the most appropriate nursing intervention. a. Direct the patient to the quiet room. b. Process the incident with the patient. c. Encourage ventilation of feelings. d. Place the patient in seclusion.
ANS: A During the escalation phase the patient is still capable of cooperation when the nurse takes charge and gives calm, firm directions. This intervention observes the principle of using the least restrictive alternative. Oral PRN medication might be used if the least restrictive alternative is not effective. Ventilation of feelings would have been used in the triggering phase. Processing the incident occurs in the recovery and depression phases. Seclusion is necessary in the crisis phase.
A patient diagnosed with a history of depression disorder tells the nurse, "My primary-care provider told me to start taking fish oil capsules to prevent heart disease. Will it cause problems with my mental illness?" Select the nurse's best response. a. "It will not cause problems. It may actually help with your depressed feelings." b. "I cannot discuss recommendations you received from another health care provider." c. "It would be better for you to take vitamins C and E. I will notify your primary-care provider." d. "Please have your primary-care provider call me so we can discuss issues related to this preparation."
ANS: A Fish oil capsules supplement omega-3 and omega-6 fatty acids. These substances not only provide cardiovascular benefits; studies have demonstrated positive results in ameliorating depression after 2 or more weeks of omega-3.
9. A patient received one dose of flumazenil. What is the nurse's next action? a. Carefully observe for benzodiazepine overdose symptoms. b. Teach the patient about dietary restrictions. c. Prevent injury during seizure activity. d. Force 500 mL oral fluids over 2 hours.
ANS: A Flumazenil, which is given to patients who have overdosed with benzodiazepines and so the nurse must be vigilant for signs that the patient is reverting to the preflumazenil state. None of the other options are relevant to this medication.
15. The nurse would expect which comment from a patient diagnosed with depersonalization disorder? a. "I feel like I'm outside my body, watching what's happening." b. "I feel as though someone is reading thoughts in my mind." c. "I know I have cancer, but the doctors can't find it." d. "When I woke up, my legs were paralyzed."
ANS: A In depersonalization, individuals feel detached from parts of their body or their mental processes. The distracters reflect somatization disorder, conversion disorder, and schizophrenia.
16. A patient is increasingly tense, pacing the hall and glaring angrily at others. Select the nurse's best comment to this patient. a. "It looks as though you are feeling upset. Please tell me what's concerning you." b. "I can see you are on the verge of losing control. What can I do to help you?" c. "You must maintain control of your feelings even if you are feeling angry." d. "I'm going to give you an injection of your medication to prevent loss of control."
ANS: A In the triggering phase the patient's behaviors are nonviolent and present no immediate danger to others. The nurse should convey empathic support and encourage ventilation using clear, calm, and simple statements.
For which patient co-morbid diagnosis would it be most important for the nurse to urge the patient to immediately discontinue using kava-kava? a. Cirrhosis b. Osteoarthritis c. Multiple sclerosis d. Chronic back pain
ANS: A Kava-kava should be used with caution in patients with liver disease because of its potentially hepatotoxic effects. The other health problems do not pose immediate dangers.
8. A patient is hospitalized with somatic blindness. The patient is unconcerned about the blindness and says, "I'm sure things will turn out all right." Which term best describes this reaction? a. La belle indifference b. Trance c. Dissociation d. Fugue
ANS: A La belle indifference refers to an attitude of unconcern or indifference about a symptom when the symptom is unconsciously used to lower anxiety. Dissociative disorders are characterized by a disruption in consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative fugue involves a lack of memory for a move or change of identify. A trance is a half-conscious state characterized by an absence of response to external stimuli.
9. An individual experiencing a heroin overdose has been given one dose of naloxone intravenously. What the priority nursing intervention is to assure patient safety? a. Close observation to determine the need for an additional dose of naloxone b. Seizure precautions for 2 hours immediately after administration of naloxone c. Acidification of urine by encouraging the patient to drink cranberry juice d. A nonstimulating environment and administration of oral fluids
ANS: A Naloxone, a narcotic antagonist, permits the individual to respond and respirations to improve. However, because most opioids have a longer lasting effect than naloxone, the effects of naloxone will wear off before the effects of the opioid. The administration of naloxone might have to be repeated. If it is not, the individual is in danger of death due to respiratory depression. None of the remaining options would support client safety when considering the effects of a heroin overdose.
22. Which individual would be most likely to experience a paradoxical reaction to a benzodiazepine drug? a. A child with attention-deficit hyperactivity disorder (ADHD) b. An adult with obsessive-compulsive disorder c. A teenager with an eating disorder d. An adult with major depression
ANS: A Paradoxical reactions to benzodiazepines are most likely in children, older adults, and persons with poor impulse control (such as ADHD) or organic brain syndromes.
17. What should the priority focus of milieu management be for a client diagnosed with dissociative identity disorder (DID)? a. Ensuring client safety b. Stimulating memory return c. Attending insight-oriented group therapy d. Gathering data about family relationships
ANS: A Patients with DID have a host personality and one or more alternates. It is not unusual for one of the alternate personalities to be depressed and wish to commit suicide or for a personality to wish to harm the others. Safety is the priority concern in care. None of the other options are directly associated with the primary issues of DID
11. What is the nurse's initial action when working with a patient with diagnosed with posttraumatic stress disorder (PTSD)? a. Assure the patient that the nurse can be trusted. b. Work with the patient to find a way to reduce stress. c. Encourage verbalization rather than physical acts to address anger. d. Support the patient's ability to evaluate past behaviors as either effective or noneffective.
ANS: A Patients with PTSD are often withdrawn and feel suspicious, detached, or estranged from others. Developing a trusting relationship might be difficult for them; however, the development of trust is fundamental to the therapeutic nurse-patient relationship. The other interventions will not be possible until a trusting relationship exists.
12. The nurse teaches a family who provides in-home care for a patient diagnosed with dementia. Which measure to facilitate environmental safety should the nurse include? a. Install gates at the tops and bottoms of stairs. b. Store medications in a clearly visible place. c. Vary the daily schedule to provide variety and stimulation. d. Include daily activities that call for use of higher cognitive functions.
ANS: A Patients with dementia often have difficulty negotiating stairs and fall. Providing gates prevents the patient from entering the stairs and falling. The other options do not apply, because they do not promote safety or might produce demands that exceed the patient's ability to function.
10. Effective management of a client diagnosed with Huntington disease is best demonstrated by which documentation made by the nurse? a. Bilateral lung sounds clear with no signs of dyspnea. b. Client denies any visual hallucinations. c. Disorientation noted only in the evenings. d. Client denies any hearing limitations.
ANS: A Pneumonia is the predominate cause of death among clients diagnosed with Huntington disease. Neither hearing dysfunctions nor hallucinations are generally associated with this disorder. Memory loss is generalized and not focused on a particular time of day.
14. A patient diagnosed with social phobia begins propranolol. The nurse should teach the patient to expect what reaction to this therapy? a. Sympathetic nervous system symptoms of anxiety will be reduced. b. A sense of euphoria for 30 minutes after taking the drug. c. Experience amnesia for the social situations that are most intimidating. d. Feeling a little drowsy but having no orthostatic hypotension.
ANS: A Propranolol is a beta blocker that interrupts the physiologic responses of anxiety associated with social phobias, such as sweaty palms. Bradycardia may be associated with lightheadedness. The other options are not likely.
17. A patient had five emergency room visits in the past month and reports, "I feel so nervous. I think I'm having heart attacks." The patient is diagnosed with panic attacks. Which comment by the nurse shows understanding of treatment for panic attacks? a. "Selective serotonin reuptake inhibitors (SSRIs) are often helpful for long-term treatment and prevention of panic attacks." b. "Benzodiazepine tranquilizers are therapeutic for long-term treatment and prevention of panic attacks." c. "No medications are particularly helpful for panic attacks. Let's work on some strategies to help you manage your fears." d. "Panic attacks result from an instability of the neurotransmitter acetylcholine. Meditation will be more helpful than drugs."
ANS: A Selective serotonin reuptake inhibitors (SSRIs) are approved for panic disorder and might be the most effective and safest agents for prophylaxis and long-term treatment. Benzodiazepines are effective during a panic attack but should not be used for long-term treatment because of the abuse and dependence potentials. It's important that the nurse show compassion for the patient's distress. Meditation may help overall, but not during panic attacks.
21. The nurse in charge of a crisis team determines that a patient who has lost control requires restraint. What is the most important factor in the safe and effective use of physical restraint? a. A calm, well-trained staff b. Taking the patient off guard c. Administering an antipsychotic drug d. Talking to the patient throughout the procedure
ANS: A Six to eight staff members are required. Each must know his or her role. With training, staff can carry out the various functions smoothly and calmly. Calmness helps ensure that physical contact is protective, rather than aggressive. Hospital protocols and legal requirements must be observed. The other options are either less important elements or inappropriate.
A neighbor asks a nurse, "Are there any resources that would help me get reliable information about alternative and complementary therapies?" Which resource should the nurse recommend? a. National Center for Complementary and Alternative Medicine b. American Psychiatric Association c. American Medical Association d. Centers for Disease Control and Prevention
ANS: A The National Center for Complementary and Alternative Medicine, a part of the National Institutes of Health, has responsibility for providing information to the public regarding the safety and efficacy of alternative therapies and for funding research for these therapies.
1. The spouse of a patient with Alzheimer disease (AD) asks, "Can you give me a simple explanation of what happened in my partner's brain?" Select the nurse's best response. a. "Dementia developed." b. "The brain became overstimulated with chemical messages." c. "Brain cells and chemical messengers that form memories are dying." d. "The substantia nigra, a tissue that makes dopamine, has degenerated."
ANS: A The pathology that should be simply explained is that AD is characterized by neuronal degeneration of the brain and deficiencies of neurotransmitters. Degeneration of the substantia nigra is associated with Parkinson disease.
3. What is the expected outcome for donepezil therapy prescribed for a client diagnosed with mild-to-moderate Alzheimer disease (AD)? a. Better daily function than without treatment b. Temporary interruption of disease process c. Remissions of varying lengths of time d. Marked decrease in memory impairment
ANS: A The patient taking donepezil may function better, but the underlying disease process would continue. None of the other suggestions results occur.
4. Select the most appropriate comment by the nurse when a depressed patient says, "What's the use in going on?" a. "Are you thinking about suicide?" b. "I am not sure I understand what you are saying." c. "Keep your hope alive. It's always darkest just before light." d. "Tell me more about your activities before you got depressed."
ANS: A The possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation. The subject must be addressed directly.
5. An older adult patient has fluctuating levels of awareness, anxiety, and appears to be picking things out of the air. The patient says, "I saw my granddaughter standing at the foot of the bed last night." The nurse should suspect which disorder? a. Delirium b. Dementia c. Schizophrenia d. Bipolar disorder
ANS: A The symptoms presented are consistent with the symptoms of delirium. Fluctuating levels of consciousness are not characteristic of dementia, schizophrenia, or bipolar disorder.
6. A patient has taken clonazepam for years to manage panic attacks but impulsively stopped the drug. Thirty hours later, the patient comes to the emergency room in distress. What is the nurse's priority action? a. Begin seizure precautions. b. Refer the patient for addiction counseling. c. Institute a behavior modification program. d. Prepare to administer flumazenil.
ANS: A There is evidence to suggest that abrupt withdrawal of clonazepam might precipitate status epilepticus. With this in mind, withdrawal from long-term use warrants seizure precautions. The patient does not have an overdose, so flumazenil is not indicated. The other options are inappropriate.
1. The nurse suspect that a patient has developed a tolerance for alcohol. Which patient statement supports that suspicion? says, The nurse assesses this phenomenon as related to: a. "I felt good from drinking a six-pack a few months ago. Now I need a few extra cans to get the same high." b. withdrawal. c. co-dependency. d. abstinence syndrome.
ANS: A Tolerance refers to the need for increasing amounts of a substance to achieve the same effects. The other terms are not related to needing more of a substance to achieve the same effect.
20. A patient who has been taking a benzodiazepine for panic attacks is to be started on buspirone. Which instruction should the nurse provide? a. "Take decreasing doses of the benzodiazepine for several days until the buspirone becomes effective." b. "Stop taking the benzodiazepines immediately. Wait 2 days, and then start the buspirone." c. "You should take buspirone only once a day. More frequent dosing can cause dependency." d. "Tolerance to buspirone may develop in about a month, requiring larger doses to be prescribed."
ANS: A Two factors suggest that the patient should take tapering doses of benzodiazepine while beginning buspirone therapy. Benzodiazepines should be tapered gradually for discontinuation to avoid withdrawal. Buspirone takes 7 to 10 days to begin to exert its therapeutic effect. The other statements about buspirone are incorrect.
23. Staff members take an aggressive patient to seclusion. Before leaving the patient in the room, the priority action should be: a. remove potentially harmful objects from the patient. b. require the patient to use the bathroom. c. have the patient lie on the bed. d. offer the patient fluids.
ANS: A Use of seclusion promotes safety, so removal of harmful objects is necessary. Seclusion is also designed to decrease stimulation. The patient might be asked if he or she needs to go to the bathroom but will not be forced to do so. In some facilities there is no bed in the room, only a mattress on the floor.
A patient who takes phenytoin (Dilantin) regularly has begun taking valerian. Patient teaching should focus on which possible consequence of the patient's action? a. Breakthrough seizures b. Spontaneous bleeding c. Impaired dentition d. Gum disease
ANS: A Valerian is thought to negate the effects of several drugs, including phenytoin, making an increase in seizures probable.
11. A patient in the emergency room has status epilepticus. The nurse should anticipate administration of what medication? a. Diazepam (Valium) b. Buspirone (BuSpar) c. Clorazepate (Tranxene) d. Chlordiazepoxide (Librium)
ANS: A Valium is the drug of choice in status epilepticus because of its rapid action. Each of the other benzodiazepines has a slower onset of action. Buspirone is not indicated to treat seizures.
3. A patient diagnosed with Wernicke-Korsakoff syndrome has the nursing diagnosis impaired memory, related to neurotoxicity of alcohol. Which statement made by the patient confirms the presences of a defining characteristic that applies to this diagnosis? a. "I sometimes make up a story to cover up for something I can't remember." b. "I often hear voices that others claim they don't hear." c. "All of a sudden, I'll have a vivid memory of the accident that killed my son." d. "Regardless of what you say, I know that the mob or CIA is out to kill me."
ANS: A Wernicke-Korsakoff syndrome is a mental disorder characterized by amnesia, clouding of consciousness, confabulation (falsification of memory) and memory loss, and peripheral neuropathy. Confabulation is a symptom typically displayed by an individual with Wernicke-Korsakoff syndrome. The individual attempts to make up for memory loss by filling in the blanks with false memories. Auditory hallucinations are often described as hearing voices that no one else can hear. Paranoid delusions are characterized by an unrealistic or unsubstantiated belief that one is in danger. None of these options are symptoms of memory impairment associated with Wernicke-Korsakoff syndrome.
15. What is the nursing care priority for a patient diagnosed with stage 7 Alzheimer disease? a. Nutrition and hydration b. Promoting self-care activities c. Supporting attempts to communicate d. Preserving problem-solving abilities
ANS: A When dementia is severe, the individual is incapable of independently meeting nutrition and hydration needs and must receive assistance. The other options refer to inappropriate emphases for care.
2. An adult tells the nurse, "I'm taking large doses of vitamin B. I read that it prevents Alzheimer disease (AD), but I don't understand how it works." Which statements would be applicable as the nurse responds to the individual? (Select all that apply.) a. "Research has not proven the effectiveness of B vitamins in Alzheimer prevention." b. "B vitamins lower the amino acid homocysteine, which is associated with a lower incidence of AD." c. "A favorable response occurs when these vitamins block NMDA." d. "B vitamins may reduce risk of AD by lowering cholesterol levels." e. "B vitamins reduce the body's inflammatory response."
ANS: A, B The keyed statements provide correct information regarding the inconclusiveness of B vitamin therapy in prevention of AD and its effects on lowering homocysteine levels. The distracters provide misleading or incorrect information.
2. A patient with suicidal impulses is placed on suicide precautions. Which measures will the nurse incorporate into the plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects. c. Maintain continuous one-on-one nursing observation. d. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. e. Keep the patient within visual range while he or she is awake, and check every 15 to 30 minutes while asleep.
ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The distracters are insufficient to assure the patient's safety.
7. How is substance dependence best defined? (Select all that apply.) a. A compulsion to use a substance b. Loss of control over use of a substance c. A physiological need to use a substance d. Continued use of a substance despite adverse consequences e. A substance-specific syndrome due to recent ingestion of a substance
ANS: A, B, C, D Dependence is marked by multiple criteria defined in the DSM-V. A substance-specific syndrome due to recent ingestion of the substance refers to substance intoxication.
5. The care plan of an agitated patient diagnosed with dementia with Lewy body (DLB) should have which assessments as priorities? (Select all that apply.) a. Level of consciousness b. Presence of auditory or visual hallucinations c. Signs of depression d. Delusional thinking e. Heart sounds
ANS: A, B, C, D Prominent symptoms of DLB include (1) fluctuations in attention and alertness; (2) recurrent visual and auditory hallucinations; (3) features of parkinsonism; and (4) rapid eye movement (REM) sleep behavior disorder. These patients tend to experience repeated falls, syncope, and unexplained loss of consciousness. Depression and delusions are also common. Heart sounds are not likely to be affected.
1. A patient diagnosed with posttraumatic stress disorder (PTSD) has frequent flashbacks and persistent hyperarousal symptoms. Which nursing interventions should be planned to effectively need the patient's needs? (Select all that apply.) a. Offer empathy and support. b. Encourage relaxation activities. c. Encourage verbalization of anger. d. Set limits when the patient begins to tell of the story of the traumatic incident. e. Help the patient associate current feelings and behaviors with trauma experience.
ANS: A, B, C, E These measures are designed to help reduce PTSD symptoms. Anger should be expressed and accepted. Patients with PTSD should learn that their feelings are commonly experienced by others with the same disorder. Recounting the traumatic event helps patients integrate the feelings of distress, so limiting such behavior is not therapeutic.
Which important points should the nurse teach a patient about using herbal preparations? Select all that apply. a. Check active and inactive ingredients. b. Discontinue use if side effects or adverse effects occur. c. Buying from online sources is preferable and cheaper. d. Avoid herbals during pregnancy and breast-feeding. e. Inform your health care provider about the use of herbals.
ANS: A, B, D, E All of the instructions are correct except the one regarding purchase of herbals. Internet purchasing of herbals might not be the best plan unless the reputation of the firm can be confirmed.
4. What assessment data suggest that a client is at risk for the development of vascular dementia? (Select all that apply.) a. History of type 2 diabetes b. Currently prescribed antihypertensive medication c. Presents early signs/symptoms of Parkinson disease d. Being treated for atrial fibrillation e. 2 pack a day cigarette habit
ANS: A, B, D, E The diagnosis of vascular dementia is determined by the presence of cerebrovascular disease and conditions that affect the vascular system. The major risk factors for vascular dementia are hypertension, diabetes mellitus, previous stroke, cardiac arrhythmias, coronary artery disease, tobacco use, and alcohol or substance abuse. Parkinson disease is not associated with this disorder since it is a neurologic not vascular in origin.
3. Which nursing interventions are appropriate for the management of a client demonstrating the behaviors associated with dementia-related "sundowning"? (Select all that apply.) a. Staff is trained to de-escalate an agitated client. b. Frequent reorientation to time and place helps minimize the effects of sundowning. c. Client is closely monitored during the late afternoon and evening hours. d. The client is provided with a safe place to pace. e. The client's family is educated to the fact that this behavior is a result of overstimulation.
ANS: A, C, D The sundown syndrome is the name given to behavior that occurs late in the afternoon or early evening when a patient with dementia becomes more confused, restless, and agitated. No definitive cause or specific treatment has been found for sundowning or to diminish its effects.
1. A nurse explains galantamine therapy to family members of a patient who is to begin treatment with the drug. What information should be included? (Select all that apply.) a. Facial flushing and leg cramps might worsen. b. It acts by making more dopamine available. c. Report slow heartbeat immediately. d. Restrict fluid intake to 1500 mL/day. e. Side effects include GI symptoms.
ANS: A, C, E Anticipated side effects include nausea and vomiting, diarrhea, facial flushing, sweating, rhinitis, bradycardia, and leg cramps. The incorrect options include fluid restriction and stimulation of dopamine. Adequate intake is necessary to address GI symptoms. Galantamine stimulates action of ACh, not dopamine.
1. What common themes apply to persons who have suicidal ideation? Select all that apply. a. Belief that life is meaningless b. Absolute intention to die c. Existence of cognitive impairment d. Experiencing hopelessness e. Feeling out of control
ANS: A, D Hopelessness, meaninglessness, and feeling out of control are the most common themes underlying suicidal ideation. The other options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are cognitively impaired.
5. Naltrexone is prescribed for a patient diagnosed with alcohol dependency. What information should the nurse provide to the patient? (Select all that apply.) a. "This medication is part of a total program to help you remain abstinent from alcohol." b. "Do not use alcohol-containing products, such as aftershave lotion and mouthwash." c. "Avoid foods that contain tyramine, such as aged cheeses and meats." d. "This medication will help reduce the likelihood of a relapse." e. "This medication will eliminate your desire for alcohol."
ANS: A, D Naltrexone, like any drug for treatment of chemical dependence, is only part of a total treatment program. It will help decrease the pleasure associated with alcohol, but it will not eliminate the desire. It reduces craving, which in turn will help reduce the likelihood of relapses. The distracters relate to disulfiram and monoamine oxidase inhibitors.
3. A patient in the emergency room is suspected to have an overdose of benzodiazepines. Which assessment findings validate this diagnosis? (Select all that apply.) a. Blood pressure 180/94 mm Hg b. Diminished reflexes c. Hypervigilance d. Somnolence e. Confusion
ANS: A, D, E Benzodiazepine toxicity may result from an overdose. Assessment findings include hypotension, somnolence, confusion, and diminished reflexes. *This question seems wrong and should be "BDE" but correct me if I am wrong :)*
3. The nurse should assure that the milieu for a patient admitted for a hallucinogen overdose should have which features? (Select all that apply.) a. Focused attention on safety b. Well lighted c. Social interaction d. Mentally challenging e. Low sensory stimuli
ANS: A, E Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."
2. A patient takes antacids, cimetidine, and phenytoin. The health care provider prescribes a benzodiazepine for anxiety. Which drug interactions is the patient at risk for experiencing? (Select all that apply.) a. Increased plasma level of benzodiazepine related to cimetidine therapy b. Increased absorption of the benzodiazepine if taken with the antacid c. Euphoria and disinhibition associated with phenytoin therapy d. Serotonin syndrome associated with cimetidine use e. Potential phenytoin toxicity
ANS: A, E Cimetidine increases the plasma level of benzodiazepines. The benzodiazepine interferes with phenytoin metabolism, thus increasing serum levels of the anticonvulsants. The distracters do not reflect actual interactions.
1. What are the most important interventions for the nurse to implement with caring for a client experiencing barbiturate withdrawal? (Select all that apply.) a. Monitoring level of consciousness b. Supporting effective respirations c. Medicating for nausea d. Monitoring for tachycardia e. Seizure precautions
ANS: A, E Delirium and seizures are considered serious withdrawal symptoms requiring seizure precautions and frequent monitoring of levels of consciousness. Nausea may be experienced but is not considered a serious side effect of withdrawal. Depressed respirations and increased heart rate are signs of barbiturate overdose.
6. Which statements accurately portray differences in the effects of alcohol between men and women? (Select all that apply.) a. Women's gastrointestinal systems have less alcohol dehydrogenase, so less ethanol is oxidized on first pass before it enters the bloodstream. b. Hot coffee increases the metabolic rate and speeds oxidation of ethanol more in men than in women. c. Women have higher proportions of body fat, which absorbs alcohol and releases it slowly. d. The microsomal ethanol-oxidizing system in women is less efficient than in men. e. Women become intoxicated more easily than men.
ANS: A, E The alcohol dehydrogenase in the gastrointestinal tissue of men who are not dependent on alcohol oxidizes a significant amount of CH3CH2OH in the gut before it enters the bloodstream. The inability of women's bodies to undergo this first-pass metabolism accounts for their enhanced vulnerability to alcohol. The remaining options do not reflect accurate research findings.
14. A patient asks, "How does Alcoholics Anonymous (AA) work?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be given a sponsor who will plan your treatment program."
ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.
An anxious patient diagnosed with diabetes says, "I'm considering taking angelica to help me relax." Select the best outcome for the plan of care. The patient will: a. report subjective feelings of improved sleep. b. identify other options to manage anxiety. c. monitor fingerstick blood glucose daily. d. rate anxiety as 5 or less on a scale of 10.
ANS: B Angelica is contraindicated in diabetes. The patient should identify other strategies to manage anxiety.
32. Which scenario presents a high risk for violence? a. A nurse empathizes with a patient who dislikes attending exercise class. b. A nurse enforces the rule that patients must attend all scheduled activities. c. A patient spends free time with a group of other patients talking about issues in their lives. d. A patient with high anxiety is allowed to remain in a quiet room instead of attending a community meeting.
ANS: B Being forced into a treatment activity reduces trust in staff. Struggles over rules are control battles. Patients who do not feel that they have control over their lives might react violently, because they believe that they have little to lose. The other options do not exemplify control battles.
16. What medication information should the nurse provide the patient newly prescribed buspirone? a. Produces profound sedation. b. Will be effective in 7 to 10 days. c. Has a high risk for development of dependence. d. Is often associated with cross-tolerance with other CNS depressants.
ANS: B Buspirone provides anxiety relief within 7 to 10 days from the time it is begun. For this reason, benzodiazepines are continued for their anxiolytic effect and gradually tapered as the buspirone becomes effective. The other options are incorrect.
13. A patient seeking treatment for anxiety says, "I can't think. My job depends on my ability to think. I need medicine, but the drugs I took a few years ago made me too sleepy. I could lose my job." What information is most important for the nurse to consider when formulating a response? a. All antianxiety medication has sedating properties. b. Buspirone alleviates anxiety without sedation or cognitive clouding. c. The patient's description of anxiety does not warrant treatment with medication. d. The patient may be trying to manipulate the nurse to assist with getting the desired prescription.
ANS: B Buspirone's action is entirely different from that of the benzodiazepines. It reduces anxiety, with its accompanying concentration and cognitive problems, but without CNS depression. The patient's description of anxiety indicates that it is interfering with daily life, so medication may be helpful. There is no evidence that the patient is trying to manipulate the nurse.
31. A staff nurse tells a peer, "I find it difficult to deal with patients who have personality disorders. They can control their behavior, whereas patients with depression truly need my services." Select the peer's most helpful response. a. "Even though it's bothering you, the patients seem to like you." b. "Our clinical nurse specialist is a good resource to help you explore those feelings." c. "Fortunately, managed care has reduced inpatient services for people with personality disorders." d. "Your comment tells me you have personal problems. Maybe psychiatric nursing is not the best practice arena for you."
ANS: B Clinical supervision can help nurses examine attitudes, reactions, and conflicts with patients on the unit and arrive at new ways of approaching patient problems. This option is the only one that recognizes that the nurse is voicing a legitimate problem for which help should be available.
1. What is the foundation of the cognitive process? a. Reasoning and logic b. Memory and learning c. Orientation and speech d. Perception and behavior
ANS: B Cognitive abilities revolve around memory and learning, with memory as foundational for learning. The other functions are dependent on memory and learning.
Select the example of complementary therapy. a. St. John's wort used with valerian b. Acupuncture used with disulfiram (Antabuse) c. Fluoxetine (Prozac) used with lorazepam (Ativan) d. Propranolol (Inderal) used with systematic desensitization
ANS: B Complementary therapy is an alternative therapy used in conjunction with conventional Western medicine. Acupuncture is an alternative therapy, and disulfiram is a Western medical therapy for alcohol abuse.
2. A tearful patient at the mental health center says, "I should be dead." What is the most important first task for the nurse in assessing this patient? a. Ascertain the lethality of the suicide plan. b. Establish a rapport with the patient. c. Determine the risk factors for suicide. d. Encourage expression of feelings.
ANS: B Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.
11. A suicide crisis line caller states, "I called to say goodbye to someone." Select the nurse's best response. a. "You seem ambivalent about committing suicide. Let's talk about that." b. "You must be feeling a lot of pain. What are you planning to do?" c. "I hope you realize how much you have to live for." d. "I think I can help you, if you'll let me."
ANS: B Expressing empathy and genuine concern while offering to work with the patient is a good beginning. Asking about the plan is appropriate and enables the nurse to assess risk. The other options fail to offer both empathy and help.
8. The nurse would expect to administer flumazenil for a patient with which diagnosis? a. Acute alcohol withdrawal b. Benzodiazepine overdose c. Benzodiazepine-resistant anxiety d. Psychotic disorder
ANS: B Flumazenil is a benzodiazepine receptor antagonist. Response occurs within 30 to 60 seconds; however, it might not reverse associated respiratory depression. Because it has a short duration of action and does not speed metabolism of benzodiazepines, administration of flumazenil might need to be repeated several times. Flumazenil is not indicated for treatment of any of the other conditions.
10. A cocaine abuser complains, "There are bugs crawling under my skin." Which term should the nurse use to document this finding? a. Confabulation b. Formication c. Synesthesia d. Euphoria
ANS: B Formication is the term used when an individual describes feeling bugs crawling under the skin. It is seen in cocaine use. The other options refer to altered sensory perceptions of sight and sound or to inventing stories to make up for memory deficit.
6. A patient diagnosed with Alzheimer disease (AD) is being treated with an acetylcholine (ChE) inhibitor drug. The patient develops facial flushing, sweating, and leg cramps. The nurse should attribute these symptoms to what process? a. Irreversible acetylcholinesterase stimulation b. Inhibition of butyrylcholinesterase (BChE) c. Neurodegeneration in the hippocampus d. Cytochrome P-450 system activation
ANS: B Gastrointestinal (GI) and other peripheral side effects of ChE inhibitor drugs are attributable to inhibition of BChE. The other options are not viable explanations.
24. A nurse is assigned to care for a patient diagnosed with moderate (+2) anxiety. Which assessment findings are most likely? a. Distorted perceptions, disorientation, and defensiveness b. Poor concentration, narrow perceptions, and irritability c. Irrational reasoning and loss of contact with reality d. Alertness, attentiveness, and accurate perceptions
ANS: B In moderate anxiety states, the body is preparing for protective action. Cognitive symptoms include difficulty concentrating, distractibility, narrowed perceptions, short attention span, tangentiality or circumstantiality, and decreased problem-solving ability. Alertness is associated with mild anxiety. Distorted perceptions are associated with severe anxiety. Irrational reasoning is associated with panic.
18. Which principle guides nursing intervention in the assault cycle? a. Contagiousness of violence b. Least restrictive alternative c. Containment d. Control
ANS: B It is a regulatory requirement to care for patients using the least restrictive alternatives. These efforts at treatment should be documented. Only when less restrictive alternatives prove ineffective can more restrictive alternatives be used.
During an admission interview, a patient who reports high levels of anxiety says, "I've been using kava-kava for about a week to relieve anxiety." When the nurse assesses mental status, expected findings would be: a. reduced coordination and slurred speech. b. intact cognitive functioning. c. slow response times. d. paranoid thinking.
ANS: B Kava-kava relieves anxiety without producing cognitive impairment, reducing mental acuity, or affecting coordination. Kava-kava is known to have an affinity for benzodiazepine receptors.
19. A health care provider prescribes lorazepam for an anxious older adult at a longer than usual dose. To assure patient safety, what is the nurse's best action? a. Assess for a history of drug abuse. b. Administer the drug as prescribed. c. Confer with the health care provider. d. Assess the patient's pupillary reaction to light.
ANS: B Lorazepam is a benzodiazepine that has a short half-life. It might be administered safely to older adult patients, although the dose should often be modified downward. It is inadvisable to give benzodiazepines with longer half-lives to older adult patients. None of the other options support safe lorazepam therapy for this patient.
21. If a patient's threshold set point for anxiety is lowered, the nurse can expect subsequent stressors to: a. have a lesser effect. b. easily reactivate the anxiety response. c. produce marked personality disorganization. d. be easily managed using familiar coping strategies.
ANS: B Lowering the threshold set point for anxiety will result in the patient becoming anxious more easily. Thus, lesser effect and ease of handling are incorrect options. Marked personality disorganization would not necessarily occur.
7. Of the drugs given to treat Alzheimer disease (AD), which one has a potential to slow neurodegeneration? a. Galantamine b. Memantine c. Rivastigmine d. Donepezil
ANS: B Memantine acts as an N-methyl-D-aspartate (NMDA) antagonist, preventing glutamine from overstimulating neurons causing neuronal death. This interference would hypothetically slow the advance of AD. The other drugs act as ChE inhibitors. This process does not slow cellular death.
8. A nurse caring for a patient who experienced an opioid overdose will give priority to which focused assessment? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic
ANS: B Opioid overdose causes respiratory depression, which is the primary cause of death among opioid abusers. The assessment of the other body systems is not the priority.
1. Which statement demonstrates a nurse's understanding of the first intervention when caring for a patient experiencing severe anxiety over an impending divorce? a. "Let me you solve the biggest problem the divorce will cause you." b. "I want you know I'll be here to keep you safe." c. "Please tell me what today's date is." d. "You can go into your room and close the door when you need privacy."
ANS: B Patients with anxiety disorders experience discomfort from the anxiety. The patient must feel safe, acknowledged, and cared for before problem-solving can begin. The nurse's first priority is to provide support and understanding. Allowing the patient to remain alone fosters social withdrawal and may allow anxiety to increase. Patients with anxiety seldom lose contact with reality.
19. A patient diagnosed with dementia is watching a crime story on television. Suddenly, the patient begins to yell, "Stop! He's got a gun." What is the nurse's best intervention? a. Administer a PRN dose of an atypical antipsychotic medication. b. Turn off the television and tell the patient, "You are safe." c. Reassure the patient that there are no guns nearby. d. Provide a snack, and put the patient in bed.
ANS: B Patients with cognitive deficits might be overwhelmed by stimuli and might misperceive something on television as occurring in reality. If this occurs, stimuli should be reduced to simplify the environment. The other measures would be somewhat less effective, because they do not include removing the offending stimulus (the television).
21. When a patient reports using both alprazolam and propofol, which inference applies? a. The combination of these medications will not result in a drug-drug interaction. b. Potentially lethal sedation and CNS depression would be expected with this drug combination. c. Tolerance to propofol probably developed very quickly in the presence of alprazolam. d. This drug combination was safe, but the patient needs close medical supervision.
ANS: B Propofol, an anesthetic, would have a predictable additive effect with alprazolam in producing significant sedation and CNS depression. While the patient needs closer medical supervision, one cannot state that the combination of drugs was safe. Tolerance to alprazolam would occur regardless of use of propofol.
A patient tells the nurse, "I've been having problems with my memory. I read some information on the Internet and started taking gingko." Select the nurse's best response. a. "The Internet does not have reliable health information." b. "More recent studies indicate that gingko does not help memory problems." c. "SAM-e has been shown to have better effects for treating memory problems." d. "Your memory problems are related to your mental illness. Herbs will not help."
ANS: B Recent studies indicate that gingko does not help with cognition or memory problems. SAM-e is useful for treating mild depression.
18. A patient diagnosed with vascular dementia does not remember family members' names. The family insistently reorients the patient, and the patient becomes more agitated. What is the most likely reason for the patient's reaction? a. He or she is using agitation to distract the family from the cognitive deficits. b. He or she is overstimulated by the reorientation and reacting negatively. c. He or she is reliving family chaos that was previously unresolved. d. He or she is experiencing guilt about the memory deficits.
ANS: B Reorientation in this case presents a demand that exceeds the patient's capacity to function and creates stress. In this situation, it would be more caring to visit the patient and communicate love and acceptance without being concerned about whether or not the patient can remember names.
10. An adult says, "I take vitamins B and E to prevent Alzheimer disease (AD), but these vitamins are so expensive." What is the nurse's most informative response? a. "Yes, these vitamins are very expensive, but it is money well spent to prevent AD." b. "There is conflicting research evidence about effectiveness of these vitamins for prevention of AD." c. "Most researchers now believe that preventing anemia is more important than taking vitamins to prevent AD." d. "Aspirin is much cheaper. You should take it instead if you want to prevent AD."
ANS: B Research findings about the effectiveness of vitamins B and E for the prevention of AD are inconclusive. The adult in this scenario may benefit more from using health care dollars on proven causes. The distracters are incorrect statements.
26. Which nursing intervention for an angry, hostile patient would best contribute to prevention and management of aggression? a. Loudly calling the patient by name b. Conveying personal interest in the patient c. Positioning oneself directly in front of the patient d. Firmly directing the patient to discontinue the behavior
ANS: B Research has indicated that the nurse's ability to be with the patient as a unique person in a unique situation is essential for dealing with potentially violent patients. De-escalation techniques include listening, empathizing, using a calm voice, offering alternatives rather than ultimatums, and conveying genuine interest in the patient and his or her well-being. The other options listed are not therapeutic.
22. A patient has been placed in four-point leather restraints following a violent episode. The nurse establishing the care plan must ensure that the restraints are removed: a. after a minimum of 12 hours of seclusion. b. every 2 hours, one restraint at a time, for 10 minutes. c. to allow the patient to eat, drink, or use the bathroom. d. after the patient is sedated with antipsychotropic medication.
ANS: B Restraints must be removed at intervals specified by agency protocol (in no case less often than 2 hours) to inspect for injuries, check circulation, and provide limb range of motion. The other options do not follow regulatory policies.
20. The effects of stress can be seen by measurement of clinical changes of the body. This statement is a tenet of which theorist? a. Freud b. Selye c. Peplau d. Sullivan
ANS: B Selye found that the effects of stress can be seen by objective measurement of structural and clinical changes in the body. Roy nursing theory uses this foundation. None of the other options deal with stress.
2. A patient diagnosed with obsessive-compulsive disorder (OCD) experiences improvement after beginning treatment with a selective serotonin reuptake inhibitor (SSRI). This phenomenon supports the theory that OCD is associated with what neurotransmitter issue? a. Norepinephrine deficiency b. Serotonin dysregulation c. Dopamine excess d. GABA deficiency
ANS: B Serotonin dysregulation is hypothesized to play a part in OCD. Relief associated with SSRIs supports this hypothesis. The other theories are nonrelated.
13. A patient in the emergency department says, "I took a drug that makes me feel like I'm outside my body looking at the world while making colors move like music." What question should the nurse ask to assess for the possible cause of the patient's experience? a. "Have you ever been diagnosed with schizophreniform disorder?" b. "Did you knowly ingest a hallucinogenic substance?" c. "Are you currently taking an antidepressant?" d. "Have you ever experienced anything like this before?"
ANS: B Symptoms of hallucinogen use (e.g., LSD) include depersonalization, loss of reality, hallucinations, synesthesia, panic, paranoid thinking, and loss of contact with reality and synesthesia, which is the blending of senses (e.g., smelling a color or tasting a sound). Data given in the scenario do not support a schizophreniform disorder or formication (abnormal crawling sensations under the skin). While an appropriate assessment question, determining if this ever happened before doesn't focus on cause.
8. Four individuals have suicide plans. Which plan evidences the highest risk for completed suicide? a. Drinking dishwashing detergent before a family meal. b. Jumping from a suspension bridge in a rural location late at night. c. Cutting the wrists in the bathroom while a patient's spouse reads in the next room. d. Overdosing on acetaminophen (Tylenol) 1 hour before the patient's spouse is expected home from work.
ANS: B The correct response presents a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.
18. What is the most important assessment question to ask a patient suspected of having a dissociative disorder? a. "Do any members of your family have problems with drugs or alcohol?" b. "Do you ever find yourself in places with no idea how you got there?" c. "How would you describe your current level of anxiety?" d. "How do you think we can be of help to you?"
ANS: B The correct response would provide information relevant to dissociative amnesia, dissociative fugue, or dissociative identity disorder, making it a good assessment question. The other questions are of no particular relevance to a dissociative disorder assessment.
1. A student tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicidal threat. Select the most critical question for the nurse to ask. a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"
ANS: B The nurse must assess the patient's access to a means to carry out the plan and, if there is access, alert the parents to remove the medications from the home. The information in the other questions is important to ask, but it is not the most critical.
15. A patient is becoming increasingly tense, pacing the hall, alternately whispering and shouting. Other patients receive hostile, suspicious glares as they walk by. Which phase of the assault cycle is the patient demonstrating? a. Crisis phase b. Triggering phase c. Escalation phase d. Depression phase
ANS: B The triggering phase is characterized by increased tension, readiness to retaliate, pacing, irritability, suspiciousness, glaring, breathing changes, and diaphoresis. The other stages are defined by behaviors specific to the stage and are not described in the scenario.
12. When caring for patients withdrawing from cocaine and amphetamines, the nurse should plan measures recognizing what unique characteristic of this withdrawal process? a. Physical withdrawal is severe and often fatal. b. Psychological withdrawal is more severe than physical. c. Physical and psychological withdrawal are equally severe. d. Physical withdrawal is a problem only if the individual used injection.
ANS: B These drugs are highly addictive. Psychological craving during withdrawal is intense. The physical signs/symptoms of withdrawal, however, are relatively mild. The degree of withdrawal signs/symptoms are not necessarily associated with the route of drug administration.
3. A patient being treated at the mental health center says, "I am having thoughts about suicide." Select the nurse's most therapeutic response. a. "Thank you for telling me, but there's nothing to worry about. We will handle it together." b. "Telling me about these feelings is a very positive action on your part." c. "It's important for you to be hospitalized as soon as possible." d. "Let's talk about the things you have to live for."
ANS: B This response gives the patient reinforcement and validation for making a positive response rather than acting out a suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem solving.
14. Which statement by a patient diagnosed with somatic symptom disorder indicates that goals for treatment are being achieved? a. "I need to be very careful about what I eat." b. "I can focus on things other than my symptoms." c. "I understand that my doctor is not an expert in everything." d. "I try to figure out my diagnosis by reading articles on the Internet."
ANS: B This statement suggests that the patient's preoccupation with physical symptoms has decreased. The other options suggest ongoing concern with his or her physical state.
2. A patient started diazepam 5 mg twice daily 6 months ago. Now, the patient requires 10 mg to achieve the same effect. What phenomenon is responsible for this situation? a. Addiction b. Tolerance c. Dependence d. Disinhibition
ANS: B Tolerance is the need for increasing amounts of a substance to achieve the same effects. The other terms, defined in the text, do not account for this phenomenon.
25. The nurse is assigned to care for a patient with moderate anxiety (+2). Which intervention will best manage the patient's signs and symptoms? a. Appropriate use of time-out b. Initiating problem-solving techniques c. Planning care to include firm guidance and control d. Assessing the need for a parenteral antianxiety drug
ANS: B Using problem-solving is an appropriate goal for a patient experiencing moderate anxiety, because these patients are capable of problem-solving with assistance. Use of time-out, providing firm guidance and control, and giving parenteral medication are interventions more often used for severe and panic-level anxiety.
6. An older adult patient is admitted with a diagnosis of delirium secondary to a urinary tract infection. The family asks whether or not the patient will recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."
ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The other options mislead the family.
Select the desired outcome for a patient who uses valerian. The patient will report: a. a lower stress level. b. undisturbed sleep throughout the night. c. an increased interest in recreational activities. d. awakening without an alarm clock in the morning.
ANS: B Valerian decreases sleep latency and nocturnal awakening, and it leads to a subjective sense of good sleep. Sleeping through the night is the best indicator that the herb was effective.
A patient takes valerian. Which instruction should the nurse provide? a. Store the herb in a cool place. b. Store the herb in a dry, dark place. c. This herb loses potency after 30 days. d. Avoid crushing the herb before taking it.
ANS: B Valerian must be protected from light and moisture.
17. An older patient had a subtotal gastrectomy after being diagnosed with stomach cancer. What long-term mental health risk related to this procedure should the nurse discuss with the patient? a. The increased risk of depression b. The risk of vitamin B12-related dementia. c. The risk of postsurgical delirium d. The increased risk of Parkinson disease
ANS: B Vitamin B12 is absorbed in the stomach, aided by intrinsic factor. This process is hindered by the loss of stomach tissue resulting from the surgery. Deficiency of vitamin B12 can lead to dementia. Regular supplementation of vitamin B12 prevents the deficiency and development of cognitive symptoms. While the development of postsurgical delirium and depression are possible they are not specific to this surgery. Parkinson disease is not associated with a subtotal gastrectomy.
4. A patient is about to begin detox for an opioid addiction. Which statements by the patient demonstrate an understanding of the signs/symptoms of the withdrawal process? (Select all that apply.) a. "I've been told to expect to be constipated." b. "My nose is going to run like I have a bad cold." c. "My legs are going to spasm painfully." d. "I'll have erection issues for several weeks." e. I'm going to have goose bumps from the chills."
ANS: B, C, E Opioid withdrawal symptoms include yawning, rhinorrhea (runny nose), sweating, chills, piloerection (goose bumps), tremor, restlessness, irritability, leg spasm, bone pain, diarrhea, and vomiting. Sexually erection is not generally affected.
2. Which interventions are appropriate for inclusion into the plan of care for a client diagnosed with Parkinson disease? (Select all that apply.) a. Speech therapy for language skills impairment b. Falls risk precautions c. Frequent depression screening d. Monitoring for obsessive-compulsive disorder (OCD) tendencies e. Education concerning risks associated with prescribed atypical antipsychotic medication therapy
ANS: B, C, E Parkinson disease is associated with postural instability, depression and anxiety, and visual and auditory hallucinations. Language skills are usually maintained and OCD behaviors are not generally observed.
1. The teaching plan for a patient beginning oxazepam should include what instructions? (Select all that apply.) a. Take the drug on an empty stomach. b. Avoid discontinuing the drug abruptly. c. Stop taking the drug if side effects occur. d. Drink only moderate amounts of alcohol. e. Avoid herbal preparations.
ANS: B, E Patients must be informed that abrupt discontinuation of benzodiazepines produces withdrawal symptoms. Use of herbal preparations such as kava-kava and valerian can produce harmful additive effects. The other options contain information that is inappropriate to teach patients.
30. A psychiatric nurse is suffering from burnout. What effect would be expected on patients under this nurse's care? Patients will probably feel: a. safe. b. empowered. c. impaired trust in the nurse. d. universality with the nurse.
ANS: C A nurse who is burned out will not spend adequate time with patients, which reduces trust. Patients feel devalued, demoralized, and powerless, and they express low levels of satisfaction with care. The patient's sense of safety and security is jeopardized. The patient looks to the nurse as a caregiver; universality is not desirable in this instance.
4. The focus of nursing care for a patient diagnosed with dementia is best demonstrated by which nursing statement? a. "The client's plan of care is individualized to meet his or her specific needs." b. "I think that reminiscence therapy will help the client remember past events better." c. "If we give the client enough time they can dress themselves appropriately each morning." d. "The client was so proud when they talked about their war experiences."
ANS: C Because memory is impaired, an individual with dementia cannot learn easily, so maintaining functioning as long as possible is important. The patient's abilities are expected to decline over time. Use of the word "optimum" suggests the changing nature of the level of functioning. Individualizing care and promoting esteem and confidence are of lesser importance than maintaining optimal function.
10. The nurse would expect a patient with which comorbid diagnosis to have a magnified response to the usual dose of a benzodiazepine drug? a. Rheumatoid arthritis b. Migraine headache c. Hepatic cirrhosis d. Osteoporosis
ANS: C Benzodiazepines are metabolized in the liver. The cirrhotic liver will slow the metabolism rate of the drugs, leading to an exaggerated response. The distracters are not associated with decreased hepatic function.
7. Which patient behavior should the nurse identify as the greatest risk for overdose with a benzodiazepine? a. Taking the drug with antacids b. Taking the drug before meals c. Combining the drug with alcohol d. Experiencing depression as well as anxiety
ANS: C Benzodiazepines taken with alcohol produce marked central nervous system (CNS) depression, even death. Antacids prevent absorption. Larger doses of benzodiazepines by themselves are rarely lethal. Depression in and of itself is not an indicator of overdose risk. Suicidal ideation might be present, but benzodiazepines by themselves are rarely lethal.
28. For which situation would clinical supervision be most important? a. A patient asks to visit with the consumer advocate. b. A new clinical nurse leader is hired to reorganize the unit. c. A newly admitted patient makes a nearly lethal suicide attempt. d. The treatment model for the unit is changed by the psychiatrist in charge.
ANS: C Clinical supervision for staff can be a tool to facilitate improved staff cohesion, morale, and ability to maintain therapeutic relationships with patients. During clinical supervision, nurses examine attitudes, reactions, and conflicts with patients on the unit and find ways of approaching problems. Nurses often require clinical supervision when working with suicidal patients. The distracters do not pose hazards to patients' well-being.
22. An anxious patient has distorted perceptions and ineffective reasoning. On an anxiety rating scale, the nurse would expect to record the patient's level of anxiety at what level? a. Mild, +1 b. Moderate, +2 c. Severe, +3 d. Panic, +4
ANS: C Cognitive symptoms of severe anxiety include distorted perceptions, difficulty focusing, and ineffective reasoning. Other symptom constellations relate to the other levels.
7. A patient has a history of alcohol abuse. Which prescription drug would cause the nurse to be most concerned about of its risk for cross-dependency? a. Hydrochlorothiazide b. Benztropine c. Chlordiazepoxide d. Olanzapine
ANS: C Cross-addiction occurs with CNS depressant drugs. Chlordiazepoxide is a benzodiazepine, so cross-dependence is expected. The other drugs will not produce cross-dependence.
5. A patient takes donepezil for Alzheimer disease (AD). Vital signs for this patient are: temperature 98.2°F; blood pressure 135/82 mm Hg; pulse 54 beats/min; respirations 18 breaths/min. Which variance should the nurse consider most likely attributable to donepezil therapy? a. Temperature b. Blood pressure c. Pulse rate d. Respiratory rate
ANS: C Donepezil selectively inhibits ACh; however, some peripheral effects, including bradycardia, are sometimes seen. The other parameters are within normal limits.
14. A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 2 Alzheimer disease (AD). Which problem common to that stage should be addressed? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self
ANS: C Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.
6. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's cultural heritage. b. Patient's insight into suicidal motivation. c. Availability of means and lethality of method. d. Quality and access to an intact social support system.
ANS: C If a person has definite plans that include choosing a method of suicide readily available to the person, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.
12. The teaching plan for a patient beginning buspirone should include information identifying this drug as having what property? a. Norepinephrine inhibitor b. Serotonergic antagonist c. Serotonin agonist d. GABA inhibitor
ANS: C It is believed that buspirone is a serotonin agonist. Because buspirone is not a benzodiazepine, it does not bind to benzodiazepine receptor sites, affect GABA, or affect norepinephrine. This accounts for its different effects and lack of CNS depression as side effects.
2. The family of a patient diagnosed with Alzheimer disease (AD) asks the nurse, "How can drugs help our parent?" Which reply provides the most realistic expectations for medication therapy? a. "Unfortunately, drugs are not helpful." b. "Drugs are available to stop the disease process." c. "Drugs can help preserve mental abilities for a time." d. "We will teach you ways of helping your parent adjust."
ANS: C Medication can elevate acetylcholine (ACh) levels and maintain cognitive abilities for a time. The progress of the disease is not slowed or halted, however. Stating that no help is available is neither therapeutic nor true. Stating that the family will be taught how to help the patient adjust might not be realistic.
A patient reports taking melatonin daily. Which aspect of the patient's health and function would be most important for the nurse to assess? a. Urinary and bowel elimination b. Energy and activity tolerance c. Sleep hygiene and patterns d. Memory and cognition
ANS: C Melatonin is used to reduce sleep-onset latency and decrease the number of nocturnal awakenings. The nurse should assess the patient's sleep patterns and hygiene
9. Which principle best applies to care of a patient diagnosed with conversion disorder? a. Structure care to provide time for rituals. b. Facilitate progressive review of the trauma. c. Give attention to the patient, not the symptom. d. Permit dependence while the symptoms are acute.
ANS: C Often, patients with conversion disorder think that their symptom makes them interesting and that they are not interesting as persons. The nurse should matter-of-factly accept the symptom without focusing on it and direct attention to the person as an individual. Two distracters refer to care of a patient with OCD and care of a patient with PTSD.
8. An older adult patient developed delirium secondary to diphenhydramine use. The patient usually took this drug for allergies but recently added a cough syrup that also contained the drug. What information is most important to teach the family? a. Older adults are more prone to delirium. b. The patient is now susceptible to progressive cognitive decline. c. Toxic medication levels often occur because of slower metabolism in older adults. d. The older adult brain has fewer neurotransmitters than the brain of a younger person.
ANS: C Older adult patients metabolize drugs more slowly as a result of declining liver function. Excretion might also be slowed. Drugs might accumulate until toxic levels are reached and cognitive symptoms appear. Anticholinergic drugs, antihistamines, and antiarrhythmia drugs are of particular concern. For this reason, families need to be aware of the drugs that older adults are using and the possible interactions among the drugs, and be alert for early symptoms of cognitive disturbance. Although older adults are more prone to delirium, it's important to provide more specific information to the family. None of the other options are correct.
10. A depressed patient admitted following a suicide attempt by overdose of sedatives states, "I don't feel like signing your papers. My partner should have let me die." What level of suicide precautions should the nurse apply? a. No precautions because the patient is in a secure setting b. Routine observation that is appropriate for all patients c. One-to-one continuous supervision by staff members d. Observation by staff members every 15 minutes
ANS: C One-to-one constant supervision is appropriate for suicidal patients who are considered at high risk: those who still have suicidal ideation, those who are angry that an attempt failed, or those who refuse to participate in their own care by agreeing to talk with staff before harming themselves. The other options are not appropriate for a patient whose suicide risk is high.
14. The nurse cares for a patient who was verbally aggressive upon admission. Three days later the patient says, "My family put me here. They wanted to get rid of me." When should the nurse be most vigilant for signs of escalating aggression? a. During one-on-one sessions b. During group activities c. During visiting hours d. In the early morning
ANS: C Patients are more likely to become aggressive at admission, at shift change, at mealtimes, during visiting hours, during the evening, when being transported, and during periods of change. In this case the patient will probably be increasingly upset if the family does not visit, because it will reinforce her thinking that they are against her. She is also likely to become increasingly upset if they do visit, because she accuses them of unfairly hospitalizing her. The other times are possible, but research has not supported them as being exceptionally high risk.
13. A patient is shouting loudly and is verbally aggressive. What analysis should the nurse make about this behavior? a. It is acceptable if directed toward staff but not toward another patient. b. It is not harmful and might prevent the patient from physically acting out. c. It is a significant warning sign that the patient may become physically aggressive. d. It allows the patient to vent frustration and alleviate stress without hurting anyone.
ANS: C Research findings indicate that verbally aggressive attacks on others are among the major warning signs of assault and battery, making the other answers mutually exclusive. Verbal aggression is part of the assault cycle.
A patient with which disorder would most likely benefit from taking St. John's wort? a. Suicidal depression b. Hypomanic symptoms c. Mild depressive symptoms d. Panic disorder with agoraphobia
ANS: C Research has found St. John's wort to be effective in treating mild to moderate depression. St. John's wort has not been found to be effective in treatment of severe depression, bipolar disorder, or anxiety disorders.
A patient diagnosed with depression tells the nurse, "I've been supplementing my paroxetine (Paxil) with St. John's wort, and it has helped a great deal." What is the nurse's priority action? a. Assess changes in the patient's level of depression. b. Remind the patient to use a secondary form of birth control. c. Educate the patient about the risks of serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.
ANS: C Research has suggested that St. John's wort inhibits serotonin reuptake by elevating extracellular sodium; thus it may interact with medication, particularly selective serotonin reuptake inhibitors, to produce serotonin syndrome.
24. A nurse who has worked on an acute psychiatric unit for 5 years has begun describing patients in insensitive ways and is less creative when dealing with patient problems. What is the most likely explanation for the nurse's behavior? a. Marginalization b. Depersonalization c. Secondary traumatization d. Poor conflict management skills
ANS: C Secondary traumatization occurs as a result of listening to and empathizing with other people's traumas. Synonyms include compassion fatigue and helper stress. The individual becomes less able to help others. Clinical supervision is indicated.
9. An adult says, "I take provastatin for my high cholesterol. It will prevent stroke and heart attack." What is the nurse's most informative response regarding the effects of this classification of drugs? a. "That's correct. I'm glad to see you taking such good care of yourself." b. "There is limited research-based evidence of the effectiveness of statin medications." c. "Some research indicates that statin drugs may also interfere with development of Alzheimer disease (AD)." d. "Perhaps you should discuss your family history with your doctor. Statin drugs may cause early development of Alzheimer disease (AD)."
ANS: C Statin drugs may provide protection against Alzheimer disease (AD), in addition to reducing the incidence of cardiovascular and cerebrovascular incidents. The distracters are incorrect statements.
17. Loneliness, related to unacceptable interpersonal behaviors is the nursing diagnosis for a patient in an alcohol rehabilitation program. Which AA step is most directly related to this problem? a. Admitted powerlessness over alcohol b. Turned our lives over to a higher power c. Made amends to persons we had harmed d. Tried to carry the AA principles to alcoholics
ANS: C Steps 8 and 9, making amends, could restore relationships and reduce social isolation from family and former friends. The other steps are less clearly related to this goal.
5. When working with a patient diagnosed with dissociative amnesia, the nurse should begin the care by implementing which intervention? a. Setting mutual goals for behavioral changes b. Instituting measures to prevent identity diffusion c. Identifying and supporting the patient's strengths d. Helping the patient develop a realistic self-concept
ANS: C Strengths serve as the foundation for later therapeutic work to promote more adaptive coping, so identifying and supporting strengths is a fundamental initial intervention. The other options are useful but are not achievable until the patient's coping mechanisms (strengths and weaknesses) have been identified.
3. Most drugs used to treat Alzheimer disease (AD) affect what system and or process? a. Monoamine oxidase reuptake systems b. Serotonin and norepinephrine production c. Cholinergic pathways, enzymes, and receptors d. The Krebs cycle and GABA neuronal inhibition
ANS: C The drugs most prescribed to treat AD are agents that restore ACh. The cholinergic pathways, enzymes, and enzyme inhibition are most related to drug action. The other systems are not relevant to AD.
3. A patient diagnosed with agoraphobia took alprazolam 0.5 mg three times daily for 3 months and then discontinued it. The next day the patient called the nurse reporting insomnia, shakiness, and sweating. What should be the focus of the nurse's assessment questions? a. Whether the patient may have also been drinking alcohol or taking antihistamines. b. The possibility that the patient has built up tolerance to alprazolam and needs an increased dose. c. The likelihood that the patient is having withdrawal symptoms from abrupt discontinuation of the drug. d. Whether the patient has progressed to panic attacks and needs a nonbenzodiazepine medication.
ANS: C The patient's symptoms suggest benzodiazepine withdrawal. The nurse knows that patients often attempt to manage their own care by discontinuing medication when they begin to feel better. Benzodiazepines should be slowly withdrawn if withdrawal symptoms are to be avoided. Drinking alcohol would result in different symptoms. Development of tolerance and panic attack symptoms would be different from those mentioned.
5. A patient has taken diazepam for 1 week for back spasms. The patient reports "feeling sleepy all the time." Which response will best address the patient's concern? a. "The dosage probably needs to be decreased." b. "Drowsiness indicates a paradoxical reaction to the drug." c. "Tolerance to the sedative effect of the drug will develop quickly." d. "Sleepiness is an unavoidable side effect of nonbenzodiazepine drugs."
ANS: C Tolerance to most side effects of benzodiazepines, including drowsiness, develops quickly. There is no need to decrease the dosage. Drowsiness is an expected reaction, not a paradoxical one. Valium is a benzodiazepine.
20. A patient whose behavior has continued to escalate despite nursing interventions begins to kick and strike out at the nurse. What is the priority nursing intervention? a. Offer an oral PRN medication. b. Have staff stand by at a distance. c. Physically control the patient's behavior. d. Allow the behavior until the patient de-escalates.
ANS: C When a patient loses control, staff must take physical control to prevent injury to the patient or others. A determination must then be made as what measures are necessary (intramuscular medication, involuntary seclusion, or restraint), keeping in mind the importance of using the least restrictive alternatives that will achieve the goal of safety.
A patient reports frequent sleep disturbances. Which preparations could be considered to help improve the patient's sleep pattern? Select all that apply. a. Yohimbine b. Vitamin C c. Melatonin d. Valerian e. SAM-e
ANS: C, D Melatonin and valerian have relaxant effects that help sleep. Yohimbine can actually cause insomnia. SAM-e may help with mild depression. Vitamin C has no effect on sleep.
A nurse assesses four new patients. Which statement causes the nurse to suspect the patient may be self-medicating with an alternative therapy? a. "I frequently have skin rashes that itch." b. "Constipation is an everyday problem for me." c. "My computed tomography scan shows that I have uterine fibroid tumors." d. "I've been very depressed and anxious since I lost my job."
ANS: D Herbals are among the most frequently used alternative therapies for depression. Four of the 12 most common herbs are used to treat or prevent psychiatric symptoms.
1. An older adult diagnosed with dementia is documented as demonstrating agnosia. Which client statements support this documentation? (Select all that apply.) a. "My hands seem to shake all the time." b. "I can't hold that cup without spilling the coffee." c. "I signed my name with that thing that writes." d. "I don't remember ever meeting you before." e. "The water came out of that thing you turn."
ANS: C, E Agnosia is defined as failure to recognize or identify objects despite intact sensory function. Describing a pencil as "that thing that writes" and a water faucet as "the thing you turn" would be examples of agnosia. Apraxia refers to inability to carry out motor activities as a result of tremors and shaking. Amnesia refers to learning and recalling information as demonstrated by not remembering.
2. How is a blackout is described? a. A comatose period related to alcohol withdrawal. b. A comatose episode associated with alcohol intoxication and poisoning. c. A time period in which a person who has used alcohol is unresponsive to the environment. d. An episode in which a person under the influence of alcohol functions normally but later is unable to remember.
ANS: D A blackout is defined as a period of time in which a drinker functions socially but for which there is no memory. The distracters omit aspects of a blackout.
4. Which assessment findings would prompt the nurse to suspect a disulfiram reaction? a. Skin rash, itching, and urticaria b. Pallor, hypotension, and muscle cramping c. Dry skin, bradycardia, fatigue, and headache d. Headache, dyspnea, nausea, vomiting, and flushing
ANS: D A disulfiram reaction consists of any combination of the following symptoms: flushing, sweating, rapid pulse, hypotension, throbbing headache, nausea, vomiting, palpitations, dyspnea, tremor, and weakness. The patient is acutely uncomfortable. The other options do not characterize the disulfiram/alcohol reaction.
Alternative therapy refers to: a. any natural therapy without a research basis. b. evidence-based pharmacologic use of plant products. c. therapies used in conjunction with Western medicine. d. therapies not generally accepted by Western medicine.
ANS: D Alternative therapies are therapies that are not generally accepted by mainstream Western medicine—for example, herbaceuticals. Some alternative therapies have been researched.
11. The nurse assesses a patient who admits to abusing large quantities of amphetamines. Assessment findings are likely to be similar to which psychiatric disorder? a. Wernicke-Korsakoff syndrome b. Bipolar disorder, manic phase c. Generalized anxiety disorder d. Paranoid schizophrenia
ANS: D Amphetamines enhance dopamine activity. The psychosis that is induced by amphetamines closely mimics the symptoms of paranoid schizophrenia. The other disorders have less to do with dopamine dysregulation.
18. What is the half-life of diazepam for an older adult likely to be? a. 10 hours b. 30 hours c. 40 hours d. 80 hours
ANS: D Because of decreased liver size and function in older adults, the half-life of benzodiazepines is markedly lengthened to 80 hours. Benzodiazepines with long half-lives are unsuitable for older adults.
1. By what mechanism does lorazepam reduce anxiety? a. Increasing serotonin levels b. Blocking dopamine receptors c. Depressing norepinephrine levels d. Potentiating gamma-aminobutyric acid (GABA)
ANS: D Benzodiazepines enhance the effects of the inhibitory neurotransmitter GABA, slowing neuronal firing. They do not affect dopamine, serotonin, or norepinephrine.
4. An emergency room patient was very anxious after a serious car accident. Lorazepam 2 mg intramuscularly was administered. One hour later, which finding indicates to the nurse that the medication was effective? a. Improved problem-solving skills b. Increased alertness c. Increased verbalization d. Reduced environmental scanning
ANS: D Benzodiazepines mute incoming stimuli and evoke less reaction. The hyperalertness and environmental scanning that accompany high anxiety are notably decreased when the drug is effective. Impaired problem-solving is a negative outcome. Because of its sedating properties, the individual might not be more alert, talkative, or active.
29. An experienced staff nurse describes feeling emotionally burdened and yet engages actively in gossip and spreading rumors about other staff members. The clinical nurse leader can assess these behaviors as consistent with: a. antisocial personality disorder. b. mild-to-moderate depression. c. depersonalization. d. burnout.
ANS: D Burnout often produces a clinical picture similar to the one described in this question. Depression cannot be diagnosed based on this information, nor can one suggest that the behavior is antisocial. Depersonalization is a symptom of burnout.
8. Which statement by a family member of a patient diagnosed with Alzheimer disease (AD) demonstrates that medication education was effective? a. "The medication affects glutamate receptors and will stabilize late-stage dementia." b. "The medication inhibits the action of dopamine and will restore short-term memory." c. "The medication offers no positive effects on performance of activities of daily living." d. "The medication inhibits breakdown of an important neurotransmitter and may slow disease progression."
ANS: D ChE inhibitors act by increasing the brain's supply of ACh, a neurotransmitter that is lacking in individuals with AD. They do not provide a cure but do often have a positive effect on cognitive function.
15. A patient states, "I have the same thoughts over and over. I feel compelled to count all my footsteps." The nurse can expect the health care provider to prescribe what medication? a. Alprazolam b. Propranolol c. Clonazepam d. Clomipramine
ANS: D Clomipramine is an antidepressant that has proven effective for obsessive-compulsive disorder (OCD). The other drugs have no proven effectiveness in treating OCD.
21. Which vector is associated with transmission of variant Creutzfeldt-Jakob disease? a. Dog ticks b. Mosquito bites c. Airborne particles d. Contaminated meat
ANS: D Contaminated meat is the vector for variant Creutzfeldt-Jakob disease. Dog ticks are the vector for Rocky Mountain spotted fever and Lyme disease. Mosquitoes are the vector for encephalitis. Airborne particles spread tuberculosis.
16. Which assessment data supports a patient's diagnosis of dissociative fugue? a. Preoccupation about having a serious disease b. Feeling of detachment from one's body c. Believing that part of the body is ugly or disproportionate d. Having no memory of assuming a new identity
ANS: D Dissociative fugue involves unplanned travel away from one's usual home and either confusion about identity or assumption of a new identity. The person does not seem to be wandering but behaves purposefully. The other options relate to body dysmorphic disorder, depersonalization disorder, and hypochondriasis.
16. An unconscious patient is brought to the emergency department with a suspected heroin overdose. Which vital signs support the suspected diagnosis? a. Blood pressure (BP) 200/100 mm Hg; pulse (P) 92 beats/min; respirations (R) 22 breaths/min b. BP 150/85 mm Hg; P 76 beats/min; R 28 breaths/min c. BP 110/70 mm Hg; P 84 beats/min; R 20 breaths/min d. BP 70/40 mm Hg; P 100 beats/min; R 10 breaths/min
ANS: D Heroin is a CNS depressant. It causes respiratory depression and lowered BP, with a compensatory rise in the pulse rate. Only the correct option follows this pattern.
10. A patient diagnosed with panic attacks frequently awakens from sleep and is diaphoretic and hyperventilating. What instruction should the nurse provide the patient to help manage this situation in the future? a. Immediately use one of the various relaxation techniques they've learned. b. Immediately use the call bell to alert staff of the panic attack. c. Get out of bed immediately and watch television as a distraction. d. Immediately breathe into a paper bag kept in the nightstand.
ANS: D Hyperventilation should be addressed immediately by having the patient breathe using a paper bag. Bringing breathing under control will help diminish the other symptoms. The calm presence of the nurse is vital to symptom reduction. The other interventions would not be effective in relieving the hyperventilation.
25. Which management practice should the clinical nurse leader of a psychiatric unit institute to enhance the therapeutic environment? a. Encourage staff efficiency and time management. b. Emphasize timely and comprehensive documentation. c. Prepare a comprehensive policy and procedure manual. d. Implement positive reinforcement for upholding professional standards.
ANS: D Institutional constraints and bureaucracy affect the caring ethic of nurses. Positive reinforcement for upholding nursing's professional standards is a management practice that supports nursing and will contribute positively to the therapeutic environment. The other options are not supportive of nursing.
5. During the rehabilitation phase of alcoholism treatment, naltrexone is prescribed. Which statement by the client demonstrates that the medication is achieving. It's intented goal to reduce the pleasurable effects of drinking alcohol. The nurse can expect to teach the patient about what medication? a. "I sleep much better than I have in years." b. "I get really sick if I drink now." c. "I'm not as nervous as I was." d. "I don't crave alcohol like I did."
ANS: D Naltrexone is an opioid receptor antagonist. It compromises the pleasurable effects of alcohol and reduces craving. Naltrexone does not affect sleep or anxiety nor is it an anxiolytic drug that makes drinking uncomfortable.
16. What information should the nurse provide the family of a client diagnosed with normal-pressure hydrocephalus (NPH)? a. It eventually develops into Pick disease b. There is currently no treatment for this condition c. Few clients regain cognitive abilities d. The related dementia is potentially reversible
ANS: D Normal-pressure hydrocephalus and vitamin B12 deficiency are two dementias that are potentially reversible. None of the other options present accurate information about NPH.
7. Which emotion experienced by a patient should be assessed by the nurse as most predictive of an increased suicide risk? a. Anger b. Elation c. Sadness d. Hopelessness
ANS: D Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.
15. Family members of an individual undergoing a 30-day alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search-and-destroy tactics to keep the home alcohol free." c. "Prevent embarrassment by covering for your loved one's lapses." d. "Make your loved one responsible for the consequences of his or her behavior."
ANS: D Often the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors. Learning to face those consequences is part of the recovery process. The other options are co-dependent behaviors or are of no help.
7. A driver was trapped in a car for several hours after an earthquake caused a bridge to collapse. A year later this person still has nightmares and re-experiences feelings of fear associated with being trapped in the car. The assessment findings are consistent with symptoms of which mental health diagnosis? a. Agoraphobia b. Panic attacks c. Generalized anxiety disorder (GAD) d. Posttraumatic stress disorder (PTSD)
ANS: D PTSD follows exposure to a traumatic event. Symptoms include those described in the scenario, as well as persistent symptoms of arousal and avoidance of stimuli associated with the traumatic event. GAD is an anxiety disorder that lacks a focus or trigger. Agoraphobia is characterized by marked fear or anxiety triggered by real or anticipated exposure to certain situations. A panic attack is an abrupt surge of intense fear or discomfort that peaks within 10 minutes.
11. A 63-year-old woman says, "I want to take estrogen to prevent Alzheimer disease (AD), but my doctor won't prescribe it." What is the nurse's most informative response? a. "Perhaps you should seek a second opinion. Estrogen clearly provides protection against AD." b. "Most researchers now believe that estrogen is not actually deficient after menopause. It simply works in different ways." c. "Most online resources indicate that estrogen provides important protection against development of AD." d. "There is conflicting evidence about whether estrogen prevents Alzheimer disease, but research clearly shows cardiovascular problems with estrogen therapy."
ANS: D Research findings about the effectiveness of estrogen for prevention of AD are inconclusive; however, estrogen therapy is clearly associated with increased risk of cardiovascular events. The distracters are incorrect statements.
11. A patient diagnosed with delirium stares at the corner of the room, wrings hands, and says, "I'm scared those snakes will bite me." What term should the nurse use to best document this event? a. Agnosia b. Disorientation c. Confabulation d. Visual hallucinations
ANS: D Seeing objects that are not visible to another person can be documented as having visual hallucinations. Agnosia related to ineffective word identification. Disorientation is generally considered confusion to person, place, or time. Confabulation is creating a story to deflect memory deficients.
13. The family of a patient diagnosed with Alzheimer disease (AD) is concerned about the patient's occasional urinary incontinence. The nurse should give which suggestion? a. Use adult diapers. b. Put a sign on the bathroom door. c. Limit fluid intake to 1000 mL daily. d. Take the patient to the bathroom every 2 hours.
ANS: D Seeing to it that the patient goes to the bathroom every 2 hours will minimize episodes of incontinence. Severe dementia might require adult diapers. Limiting fluids is never advised. Placing a sign on the bathroom door is effective only when the patient recognizes the need to void but is unable to find the bathroom.
23. A patient is demonstrating severe (+3) anxiety. Nursing interventions should center around which patient need? a. Encouraging ventilation and refocusing attention b. Discussing possible sources of anxiety c. Taking control to guide the patient d. Decreasing stimuli and pressure
ANS: D Severe anxiety requires intervention to relieve the heightened tension and discomfort that the patient is experiencing. Perceptions are often distorted, focusing is difficult, and problem-solving is impossible, even with help. Environmental simplification and kind, firm directions are approaches to decreasing stimuli and pressure. The other options will not be as effective.
12. Social-psychological models describe aggression as: a. intentional harm toward others. b. an unhealthy way of managing anxiety. c. a conflict with others expressed aggressively. d. a response to frustration in the social environment.
ANS: D Social-psychological models of aggression focus on the interaction of individuals with their environment and locate the source of anger in interpersonal requirements and frustrations. The other options are not consistent with this model.
4. A patient's family member died in the 9/11 World Trade Center explosion. The patient says, "I can't go into tall buildings because I get sweaty, my heart races, and I can't breathe. I get terrifying feelings the building will explode." Which response demonstrates the nurse's understanding of this symptoms/signs? a. "What rituals do you preform to control your anxiety?" b. "Have you ever been diagnosed with generalized anxiety disorder (GAD)?" c. "Your symptoms/signs suggest possible acute stress disorder (ASD)." d. "It appears you are experiencing a specific phobia associated with your family's tragedy."
ANS: D Specific phobias typically develop after a traumatic event or observing others going through a traumatic event. The extreme physical and emotional reactions are consistent with panic-level anxiety. Rituals are associated with obsessive-compulsive disorder (OCD). GAD lacks a general focus while an acute stress disorder would not be associated with an event so long ago.
19. A patient's behavior has continued to escalate despite nursing interventions designed to achieve de-escalation. The patient begins to kick and strike at staff. This behavior evidences which phase of the assault cycle? a. Triggering b. Depression c. Escalation d. Crisis
ANS: D The crisis phase is characterized by a patient's loss of self-control with fighting, hitting, kicking, scratching, biting, and throwing things. Each of the other phases has selected characteristics, none of which were described in the scenario.
19. Which term describes the final stage in the normal process of anxiety? a. Panic b. Crisis c.Disorganization d. Coping
ANS: D The individual moves from experiencing the symptoms of anxiety to the use of coping behaviors to alleviate these symptoms. Panic is a level of anxiety. Crisis involves disorganization, which is not always the end product of anxiety. Disorganization is not always experienced as the product of anxiety.
5. A nurse counsels a patient who made a suicide attempt 3 days ago. Select the nurse's most therapeutic comment. a. "I'm glad you voluntarily admitted yourself to the hospital. We can help you here." b. "When you have bad feelings, try to remember the good things about your life." c. "You must take control of your problems and try to find solutions." d. "Let's discuss some ways to solve your most important problem."
ANS: D The nurse helps the patient to develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by generating and testing ways to solve them. The distracters present overwhelming approaches to problem solving.
3. A patient says, "I have the same continuous and intrusive thoughts that my house is contaminated with lethal bacteria. I spend hours cleaning the walls, floors, and furniture." These symptoms are most consistent with which diagnosis? a. Social phobia b. Panic disorder c. Somatoform disorder d. Obsessive compulsive disorder (OCD)
ANS: D The patient's persistent intrusive thoughts are obsessions, and the need to continually clean is a compulsion. Hence, the patient's disorder can be identified as OCD. The symptoms are not consistent with a fear of interacting with others, extreme fear, or physical symptoms that have no physiological basis.
6. A patient diagnosed with obsessive-compulsive disorder (OCD) paces up and down the corridor counting every floor tile. How should the nurse address the patient's behavior? a. Offer to play cards with the patient in the dayroom as a distraction. b. Encourage the patient to focus by asking, "Why are you pacing and counting?" c. Interrupt the behavior by taking the patient's arm and escort the patient to a quiet area. d. Permit the patient to pace and count while monitoring for safety.
ANS: D The performance of the pacing-counting ritual is decreasing the patient's anxiety. Stopping will increase anxiety. Rituals should be restricted only when they physically endanger the patient. The other options will not promote anxiety reduction for this patient.
A patient asks, "I want to consult an herbalist. What should I do to make sure I don't get some impostor?" The nurse should advise the patient to first ask the provider: a. "How much will treatments cost?" b. "Have you treated this condition before?" c. "Do the treatments pose any dangers to me?" d. "What group has certified you in this practice?"
ANS: D The priority question is whether the individual is credentialed to practice via license or certification. Either credential suggests, but does not guarantee, some degree of knowledge and competence.
12. Which statement made by an individual diagnosed with PTSD best indicates that treatment was effective? a. "I'm drinking less now that I've faced my problems." b. "I feel like the accident happened to someone else." c. "I sleep for 3 to 4 hours a night without nightmares." d. "My artwork distracts me and eases my anxiety."
ANS: D Treatment has been successful when an individual can use coping mechanisms to move forward and find meaning in the traumatic event. Continued use of drugs and alcohol is maladaptive. Continued sleep disturbances and insomnia as well as dissociation or depersonalization do not indicate that treatment was effective.
9. A novice nurse on an inpatient psychiatric unit says to a colleague, "My newest patient has been diagnosed with schizophrenia. At least I won't have to monitor for a suicide risk." Select the colleague's most accurate response. a. "Our structured milieu provides a safe environment for all patients, regardless of their suicide risk." b. "Delusions usually protect a patient with schizophrenia from thinking about suicide." c. "Suicide is a higher risk for adolescents than for patients with schizophrenia." d. "Any mental illness substantially increases the risk of suicide."
ANS: D Up to 15% of patients with schizophrenia and other mental illnesses die from suicide, more than adolescents or older adults. Delusions offer no protection.
2. Which assessment findings support a nurse's suspicion that a patient has possibly been abusing inhalants? (Select all that apply.) a. Perforated nasal septum b. Hypertension c. Pinpoint pupils d. Confusion e. Ataxia
ANS: D, E Inhalants are usually CNS depressants, giving rise to confusion and ataxia. The other options relate to cocaine snorting and opioid use.
3. Which receptors carry out primary functions of the parasympathetic nervous system? (Select all that apply.) a. NMDA b. COX-1 c. COX-2 d. Nicotinic e. Muscarinic
ANS: D, E Nicotinic and muscarinic receptors are involved in the action of ACh, the primary neurotransmitter for the parasympathetic nervous system. The other options are not involved.
A patient who is receiving an antipsychotic drug is restless, paces, and cannot sit still when watching television. The nurse should use which term to document these findings? a. Dystonia b. Akathisia c. Dyskinesia d. Bradykinesia
B A patient with akathisia describes feeling restless, jittery, and unable to sit, and has restless legs that feel better only if the patient is moving. Dystonia refers to sustained, twisted muscle contractions. Dyskinesia refers to jerky motions. Bradykinesia refers to slow movement.
How does a multiaxial diagnostic and classification tool contribute to successful treatment of persons with mental illness? a. It provides for consistency and continuity in formulation of diagnoses. b. It assesses more dimensions of illness than simply the medical diagnosis. c. It establishes prevalence rates for psychiatric disorders across various cultural groups. d. It provides treatment algorithms for psychotherapeutic management of persons with mental illness.
B A multiaxial tool looks more holistically at the individual. The DSM-V-TR axes consider medical conditions, presence of personality and developmental disorders, relevant psychosocial and environmental factors, and global assessment of functioning. The other options listed are not advantages that contribute to treatment success.
An older adult patient who takes trihexyphenidyl begins taking diphenhydramine (Benadryl) for cold symptoms. The nurse should carefully monitor this patient for what possible anticholinergic effect? a. Polyuria b. Tachycardia c. Constipation d. Hypothermia
B An anticholinergic effect on the vagus nerve causes tachycardia by removing the braking effect on the sinoatrial node. The additive effects of trihexyphenidyl and diphenhydramine would be likely to produce tachycardia, which could lead to cardiac decompensation in an older adult. In terms of priority of problems, hyperthermia may occur later, after toxic levels of anticholinergics had been ingested; constipation would be less life-threatening than cardiac decompensation. Anticholinergics cause urinary retention, not polyuria.
The nurse providing patient teaching regarding an anticholinergic drug demonstrates an understanding of this classification of medication by including what instruction? a. Limiting fluid intake to 1000 mL/day b. Limiting strenuous activity on hot days c. Eating small, frequent meals to decrease nausea d. Wearing adequate clothing to prevent hypothermia
B An anticholinergic side effect is decreased sweating. Sweating produces body cooling through evaporation. Heat stroke is a greater possibility when the body cannot cool itself. The other options have no particular relevance to anticholinergic therapy.
An elderly nursing home resident has been diagnosed with type 2 diabetes, hypertension, and dementia. The patient begins taking an antipsychotic drug for agitation. Tremor and bradykinesia develop, so an anticholinergic is added to the drug regimen. Within 3 days, the patient displays a marked cognitive deficit. Which medication is the most likely cause of the cognitive change? a. Antihypertensive b. Anticholinergic c. Antipsychotic d. Antidiabetic
B Anticholinergic medications often produce cognitive changes in older adults. Although the other medications listed might produce untoward effects, because the symptoms appeared after the introduction of the anticholinergic, one would suspect this drug first.
A patient prescribed haloperidol for a diagnosis of schizophrenia has a dystonic reaction. Benztropine 2 mg is given intramuscularly and then continued orally twice daily. Three days later, the patient has fever, disorientation, and tachycardia. What is the most likely cause of the latest signs and symptoms? a. Tardive dyskinesia has emerged. b. Benztropine toxicity has developed. c. Extrapyramidal symptoms have returned. d. Dopaminergic benztropine effects have exacerbated the psychosis.
B CNS hyperstimulation from anticholinergics causes fever, disorientation, excitement, agitation, delirium, and hallucinations as well as cardiovascular, urinary, and gastrointestinal symptoms. Collectively, these findings indicate anticholinergic toxicity. The symptoms described in the scenario do not accurately reflect any of the other options.
An adult diagnosed with schizophrenia was started on clozapine 4 days ago. At 2100 today, the patient's vital signs are temperature 101°F; pulse 143 beats/min; respirations 20 breaths/min; blood pressure 100/60 mm Hg. What is the nurse's best action regarding the 2100 dose of clozapine? a. Recognize the alterations in vital signs as typical for early therapy, and administer the medication. b. Hold the medication, and notify the health care provider. c. Give the drug and continue to monitor vital signs every 4 hours. d. Postpone the dose until vital signs are normal
B Clozapine might cause agranulocytosis, a potentially fatal illness. Any symptoms or signs of infection raise suspicion and call for investigation of white cell differential counts. Clozapine should be withheld until the white blood cell (WBC) count and absolute neutrophil count (ANC) are known. Administering the drug has the potential for further lowering the WBC count and ANC.
A patient diagnosed with schizophrenia expresses fear of being pursued by hostile forces. The patient carries a tablet and writes notes in a code. The patient says, "I'm the only one who understands this code." What is the priority nursing diagnosis? a. Impaired environmental interpretation syndrome related to inability to reason b. Disturbed thought processes related to thinking not based on reality c. Risk for other-directed violence related to persecutory delusions d. Powerlessness related to feelings of persecution
B Disturbed thought processes based on thinking not based on reality is a priority diagnosis for a delusional patient. Impaired environmental interpretation is more useful for an individual who has been disoriented for more than 3 months. Risk for violence might be considered if the patient had given any indication of wishing to attack his persecutors or of willingness to fight back if personally attacked. Further investigation is necessary. No information was presented to suggest that the patient feels powerless. This would require further investigation.
A nurse works in a geropsychiatric unit. Which intervention will be most helpful for patients experiencing confusion and disorientation? a. Door locks b. Environmental cues c. Community meetings d. Psychoeducational groups
B Environmental cues can be helpful to patients with cognitive impairment, such as signs with names or graphic images, orientation boards, and color-coding locations. These elements are usually present on dementia units and geropsychiatric units. Community meetings and psychoeducational groups may be helpful but may also overstimulate patients with dementia. Door locks help the staff rather than patients.
Which historical event marked the beginning of the evolution of psychotropic medications? a. The selective serotonin reuptake inhibitor (SSRI) classification of antidepressants was developed. b. Lithium was discovered in Australia. c. Clozapine, the first atypical antipsychotic drug, was marketed in the United States. d. Chlorpromazine, the first antipsychotic, is "discovered" in France.
B Evolutionary events in the development of psychotropic drugs changed the care environment for patients with mental illness and had significant effects on the nurse's role. The discovery of lithium in Australia in 1949 was the initial event that began the evolution of psychotropic medications. All the remaining options followed.
12. Bioavailability of orally administered drugs is initially associated with which physiologic phenomenon? a. Rate of renal excretion b. First-pass metabolism c. Synaptic transmission d. Blood-brain barrier
B First-pass metabolism in the liver reduces the bioavailability of orally administered drugs. The other options do not occur first.
A patient diagnosed with depression has a need for divisional activities. Which team member is best qualified to assess the patient's leisure needs and plan the interventions? a. Occupational therapist b. Recreational therapist c. Exercise physiologist d. Chaplain
B Recreational therapists are qualified to assist patients to find leisure interests that will enable the patient to learn to balance work and play. The other professionals do not have this focus.
A patient displays disorganized speech and behavior as well as a flat affect. The patient prefers to sit alone and often appears to be listening and responding to unseen stimuli. What should the nurse do to begin a therapeutic relationship? a. Take the patient to a medication education class. b. Offer a simple activity, and sit with the patient. c. Ask the patient what the voices are saying. d. Quietly watch television with the patient.
B For withdrawn patients, nurses should begin with undemanding one-to-one interactions. Providing a simple activity might help the patient focus on the here and now and provide a basis for reality-oriented communication. Watching television together does nothing to build trust. Medication education might be of little benefit if the patient is hallucinating and unable to pay attention to what is being taught. Asking what the voices are saying time after time is not beneficial to the patient, who needs to be distracted from them and focus on the real world.
A patient began trihexyphenidyl therapy for treatment of drug-induced parkinsonism. Which finding demonstrates a positive response to the medication? a. Blood pressure returns to patient's normal range. b. Gait is steady with decreased rigidity. c. Patient reports fewer feelings of depression. d. Patient has tremors with voluntary movement.
B Gait disturbance, tremor, bradykinesia, and rigidity are symptoms of drug-induced parkinsonism. Reduction in these symptoms constitutes a positive outcome. The other options are not expected outcomes.
Which patient would benefit most from closed, process-oriented group therapy? a. Adult with disorganized schizophrenia admitted to an acute psychiatric unit b. Outpatient living independently with chronic low self-esteem and anxiety c. Patient receiving treatment in an assertive community treatment program d. Resident of a group home attending a partial hospitalization program
B Group therapy is seldom an option during short-term treatment. The individual with low self-esteem, anxiety, and living independently meets criteria for being able to develop plans for change and coping, and is able to attend group sessions long enough to benefit from group therapy's curative features. A patient in an assertive community program is someone who receives care from a team that seeks him or her out in the community. Group home residents might or might not be suitable for inclusion in group therapy sessions.
Considering potency, what should the nurse closely monitor a patient receiving a traditional high-potency antipsychotic medication for: a. adrenergic effects. b. extrapyramidal side effects. c. anticholinergic side effects. d. changes in pain perception.
B High-potency antipsychotics are more likely to cause extrapyramidal side effects (EPSEs) than low-potency antipsychotics. The other effects are not related to potency classification.
During the community meeting a patient says, "I'm having problems in my sex life." The leader of the meeting should make which response to support effective patient care? a. "Go on. We are here to listen." b. "That's a topic to discuss with your therapist today." c. "How does everyone else feel about discussing this topic?" d. "Perhaps you should leave the meeting until you are in better control."
B Individual problems are not dealt with in community meetings. It is suggested to patients that individual issues be discussed with one's therapist. The focus of community meetings is on matters of general concern to the group at large. When the patient is informed of when and where to address the individual problem, it should be done in a nonpunitive manner.
An adolescent has an autism spectrum disorder. Which psychoeducational group topic would best meet the patient's needs? a. Signs of relapse b. Interpersonal skills c. Anger management d. Medication management
B Individuals with autism spectrum disorders almost universally have impaired relationships and need help learning effective social skills to support relationships. Anger and medication management might or might not be needs of such individuals. Deficits are constant, so relapse is not an issue.
A patient says, "I'm like a wind-tossed leaf. My goal is to find meaning in life." The nurse should consider referring the patient to which group? a. Self-help b. Spirituality c. Reality orientation d. Psychoeducational
B Lack of meaning in one's life is a spiritual concern. Referral to a spirituality group has potential for helping the client. The other options do not address the patient's expressed concern.
A patient receiving a traditional low-potency antipsychotic medication should assess closely for what possible peripheral nervous system related side effect? a. Urinary frequency b. Urinary retention c. Hypertension d. Diarrhea
B Low-potency antipsychotics tend to cause anticholinergic side effects. Urinary retention and other anticholinergic effects are important findings for which the nurse should be alert. The other effects would not be expected.
Parents of a 17-year-old patient diagnosed with schizophrenia ask the nurse what the future will be like for their child. The nurse's answer should be based on what knowledge concerning the usual course of this illness? a. A steady lessening of symptoms until stability is achieved. b. Characterized by alternating acute and stable phases. c. Totally different for each individual patient. d. Progressive deterioration.
B Most patients with schizophrenia experience alternating acute and stable phases throughout life. Complete and permanent remission is rare. The course of the illness might be somewhat different from individual to individual, but the alternating phases are seen more often than any other course.
A patient who has taken antipsychotic medication for a year presents with these signs and symptoms: jaundice, headache, pruritus, and abdominal discomfort. Which finding should be documented as objective data? a. Pruritus b. Jaundice c. Headache d. Abdominal discomfort
B Objective data are obtained by the nurse through direct observation or measurement. Jaundice is seen by the nurse. The other choices are considered subjective data.
A patient taking clozapine reports, "I get plenty of vitamin C by drinking 8 ounces of grapefruit juice each morning." How should the nurse respond? a. "High doses of vitamin C support the immune system and general good health." b. "Let's talk about better juice choices, because grapefruit juice can cause a bad reaction while taking clozapine." c. "Grapefruit juice lessens the effectiveness of your medication. You might need a dosage change." d. "New research shows papaya juice is a better source of vitamin C than grapefruit juice."
B Only the correct option provides vital information based on the cytochrome P-450 enzyme system's involvement in drug metabolism. Clozapine metabolism is inhibited by the ingestion of grapefruit juice, making the likelihood of a toxic reaction to the drug more likely, because the drug accumulates in the body.
A patient diagnosed with schizophrenia expresses fear of being pursued by hostile forces. The patient carries a tablet and writes notes in a code. The patient says, "I'm the only one who understands this code." What is a realistic and desirable outcome for this patient? a. The patient will express a willingness to be supervised by staff by day 2. b. The patient will report feeling safe from harm by others by day 3. c. The patient will allow the nurse to read coded writings by day 2. d. The patient will recognize the need for medication by day 1.
B Reporting that he is no longer afraid of harm emanating from hostile forces would suggest a reduction in delusions. Allowing the nurse to read the coded writings or wishing to have a staff member nearby do not necessarily suggest improvement in reality-based thinking. Stating that he needs medication to clear his thinking by day 1 is not realistic, because delusions are fixed beliefs.
Of the patients the nurse will see at the mental health center, which one should be assessed most carefully for extrapyramidal side effects (EPSEs)? a. 59-year-old man with a 20-year history of severe mental who is prescribed olanzapine. b. 18-year-old woman experiencing a first episode of schizophrenia who is prescribed haloperidol. c. 26-year-old man diagnosed with generalized anxiety disorder who is prescribed lorazepam. d. 30-year-old woman diagnosed with depression who is prescribed amitriptyline.
B Risk factors for EPSEs include female gender, first episode of schizophrenia, older adults and people diagnosed with an affective disorder. The other patients are at lower or no risk because of taking an atypical antipsychotic, a tricyclic antidepressant, and an antianxiety drug.
Which drug would a nurse expect to produce a favorable response for both positive and negative symptoms? a. Haloperidol b. Risperidone c. Fluphenazine d. Trifluoperazine
B Risperidone is an atypical antipsychotic. It has proven to be effective in managing both positive and negative symptoms of schizophrenia in many patients. The other drugs are traditional antipsychotics, all of which are more effective in managing positive symptoms.
Which outcome of hospital-based psychiatric care should the nurse consider a priority for a patient to achieve before discharge? a. Referral for vocational rehabilitation b. Safe level of functioning c. Medication stabilization d. Problem resolution
B Safe level of functioning is of paramount importance before a patient returns to the community. Work toward problem resolution and medication stabilization can continue in the community. Referral for aftercare might or might not be necessary, depending on a patient's needs.
A large mental health facility has several specialized units. A patient admitted for alcohol withdrawal asks, "Will I be with patients who have schizophrenia or dementia while I'm here?" Select the nurse's best answer. a. "No. Patients with alcoholism often become violent and must be isolated from our general psychiatric population." b. "No. Patients with needs for alcohol detoxification are treated on our acute substance abuse unit." c. "Yes. Our patients often help each other, so they are all on the same unit." d. "Your question leads me to wonder if you're feeling frightened."
B Specialty units serve specific populations of patients. The patient in need of alcohol detoxification will receive care on an acute substance abuse unit. It's important to answer the patient's question. Afterward, the nurse can explore the patient's feelings. Violence is a risk during alcohol withdrawal, but the risk alone is not a reason to isolate the patient from others.
Which statement by the nurse indicates an understanding of the safe and effective administration of an anticholinergic medication? a. "Avoid eating foods high in tyramine." b. "Do not abruptly stop taking the drug." c. "Take oral medications on an empty stomach." d. "Take a multivitamin and mineral supplement daily."
B Tapering off the drug over a 1-week period is advisable instead of abruptly stopping the drug. This prevents uncomfortable withdrawal symptoms. Avoiding foods high in tyramine is important teaching for patients taking monoamine oxidase inhibitors (MAOIs). The other statements are not applicable to this classification of medications.
An antipsychotic medication is prescribed for a 72-year-old patient with a psychiatric disorder. It is most critical for the nurse to obtain information about which preexisting condition by asking what assessment question? a. "Are you being treated for cataracts?" b. "Have you ever been diagnosed with heart disease?" c. "Do you have diabetes mellitus? d. "Are you being treated for chronic bronchitis?"
B The anticholinergic and antiadrenergic effects of this drug might produce reflex tachycardia and/or arrhythmias. Individuals with known heart disease must be carefully evaluated before and during therapy. The remaining options are not influenced as directly by this medication.
The family of a patient with type I schizophrenia asks, "Did this illness occur because of all the chaos in our family?" What is the nurse's best response? a. "It is likely that the chaos in your family caused the disorder. It is very important for every family member to keep calm." b. "Stress in your family may make the disorder more difficult to manage, but it is not the cause." c. "Too little is known about the cause of this illness for anyone to speculate." d. "That question would be best answered by the psychiatrist."
B The concept of disordered family interaction as the cause of schizophrenia is largely outdated. There is more reliance on the dopamine hypothesis or the stress-vulnerability model at present. Two options are dismissive, and the other suggests that the nurse is not qualified to give information.
What is the best way to support the need for physical activity when the patient moves from acute care into community-based care? a. Use video-based exercise programs on television. b. Enroll in a swim class at the community center. c. Attend outpatient psychoeducational groups. d. Join a social club.
B The key combination affords the patient physical exercise as well as opportunities for social interaction at a community center. Exercise on television is solitary. Psychoeducational and social interaction do not achieve the goal.
1. Which patient would be most at risk for adverse reactions when administered a highly protein bound medication? a. A healthy adolescent b. A 76-year-old patient with malnutrition c. A woman in the second trimester of pregnancy d. An adult with a fractured femur from a sporting accident
B The older malnourished patient would have fewer serum proteins to bind the drug; therefore, higher amounts of free drug would be available to act immediately. The patients described in the distracters would have normal protein levels, so the drug would be bound as expected.
A patient is to be discharged on a maintenance dose of a high-potency antipsychotic medication. Which remark indicates that discharge teaching about the medication was effective? a. "I will be able to have a few glasses of wine." b. "I have to use sun block when I go to the beach." c. "It is important for me to dress warmly in all seasons." d. "If I miss a dose, I will take an extra one the next day."
B The patient understands that antipsychotics cause photosensitivity and sunburn with minimal exposure to the sun. The other remarks suggest that the patient does not understand the additive effects of the antipsychotics and other central nervous system depressants, and does not understand what to do in the event of a missed dose.
A patient takes a psychotropic medication that affects norepinephrine receptors. The patient reports, "It feels like my heart is pounding in my chest." What effect is the drug having on the norepinephrine receptors? a. Inhibition b. Activation c. Paradoxical d. Antagonism
B The patient's complaints indicate activation of norepinephrine receptors. The medication has stimulated the action of beta1-receptors. None of the other options correctly identifies this outcome.
A patient takes a psychotropic medication that affects acetylcholine receptors. The patient reports dry mouth and constipation. What effect is the drug having on the acetylcholine receptors? a. Activation b. Antagonism c. Stimulation d. Paradoxical
B The patient's reports indicate suppression of the parasympathetic nervous system, which is associated with antagonism of the action of acetylcholine. The results described are not associated with any of the other options
Which principle is applicable to nursing care of patients with all types of psychopathology? a. Avoid competitive situations. b. Treat patients as individuals. c. Confront patients with consequences of behavior. d. Assume that patients will make self-enhancing decisions.
B Treating all patients as individuals is a key aspect of showing respect. The distracters are not universally therapeutic measures.
Bearing in mind the function of the blood-brain barrier, what is the danger associated with administering large doses of water-soluble drugs? a. Rapid development of tolerance b. High risk of adverse systemic effects c. Liver's inability to metabolize water-soluble drugs d. Rapid passage into the brain increasing the risk of overdose
B Water-soluble drugs penetrate the blood-brain barrier slowly and in insignificant amounts. A dose high enough to affect the brain would invariably cause adverse systemic side effects. The other effects are not related.
When patients are treated with antipsychotic medications, a variety of side effects and adverse reactions may occur. Which possible reaction presents the highest risk for patient injury? (Select all that apply.) a. Akathisia b. Dystonic reaction c. Neuroleptic malignant syndrome (NMS) d. Tardive dyskinesia
B, C, D NMS is considered a medical emergency requiring immediate intervention to save the patient's life. A dystonic reaction is extremely uncomfortable and requires swift intervention to restore patient comfort. Akathisia is uncomfortable but is not considered an emergency. Tardive dyskinesia is a serious, possibly unremitting problem that might require discontinuing the medication. It develops over weeks, months, or years.
What information should the nurse include in patient teaching about psychotropic medication? (Select all that apply.) a. Drug pharmacokinetics b. Common drug interactions c. Management of common side effects d. Descriptive list of possible adverse effects e. Information regarding cost of the medications prescribed
B, C, D Teaching about how to manage common annoying side effects, such as dry mouth and orthostatic hypotension, can promote medication compliance by the patient. Knowing what side effects to report promotes patient safety. In addition, knowing about common drug-drug interactions, such as the potentiating effects of alcohol on sedating drugs, promotes patient safety. Providing written materials is helpful to patients who can then refer to these resources rather than having to rely on memory. Pharmacokinetics is not an issue generally discussed with patients. Information related to cost is not considered a component of medication education.
A patient who takes haloperidol 10 mg/day orally developed restlessness, agitation, and an inability to sit still. The nurse then administered a PRN dose of haloperidol 5 mg intramuscularly. One hour later the patient's symptoms were worse. What is the most likely explanation for the increase in symptoms? a. The PRN medication has not yet taken effect. b. The patient needs an increase in the dosage of haloperidol to control the rising agitation. c. The patient was experiencing akathisia, which worsened after receiving the haloperidol medication. d. The nurse should consider an adjunctive dose of an antianxiety drug such as lorazepam.
C Akathisia is characterized by subjective feelings of restlessness accompanied by the inability to sit still and the need to pace. It is an EPSE of antipsychotic medication, made more intense by higher doses of medication and use of PRN doses. It is unnecessary to change to a more sedating drug. The addition of an antianxiety drug is unnecessary.
A patient diagnosed with schizophrenia and well managed with medication therapy tells the clinic nurse, "I stopped taking my antipsychotic medication 2 days ago." What assessment finding would the nurse expect at this visit? a. Mood instability b. Paranoid delusions c. No evidence of symptoms d. Mental clouding and confusion
C Antipsychotic drugs accumulate in fatty tissue and are released slowly. This explains why symptoms might still be controlled for several days after discontinuing the drug.
What is the most prevalent psychopathologic condition diagnosed in the United States? a. Schizophrenia b. Mood disorder c. Anxiety disorder d. Alcohol dependency
C Anxiety disorders are the most prevalent, followed by mood disorders and alcohol disorders.
A patient who has taken three doses of haloperidol suddenly cries out for help. The nurse observes that the patient's eyes are rolled upward in a fixed gaze. The nurse should administer which drug from the patient's PRN list? a. Vitamin E b. Carbidopa c. Benztropine d. Amantadine
C Benztropine is an anticholinergic that can be given orally or parenterally in case of an emergency, such as oculogyric crisis or dystonic reaction. The other options would not relieve the dystonia.
A patient is being switched to clozapine from therapy using a traditional antipsychotic. The patient asks, "What's the advantage of the new drug?" What is the nurse's best response? a. "It is much less expensive." b. "It has a lower risk for seizure activity." c. "It is sometimes effective when other drugs fail." d. "It has a lower risk for causing blood abnormalities."
C Clozapine is often effective against refractory schizophrenia. The distracters are incorrect statements.
What is an initial short-term outcome for a withdrawn, socially isolated patient diagnosed with schizophrenia? a. The patient will participate in scheduled activities. b. The patient will identify barriers to social communication. c. The patient will consistently interact with an assigned nurse. d. The patient will share feelings of isolation with group members.
C Consistently interacting with one person reduces isolation. One-to-one interaction is the basis for developing trust and a therapeutic nurse-patient relationship. Later, the patient's willingness to participate in activities or discuss feelings indicates progress.
A nurse administering a selective serotonin reuptake inhibitor (SSRI) antidepressant should carefully observe the patient for symptoms related to what possible reaction? a. Dopamine excess b. Decreased GABA level c. Increased serotonin level d. Decreased acetylcholine level
C Depression is thought to be related to decreased amounts of the neurotransmitters norepinephrine and serotonin. SSRIs increase the reuptake of serotonin, increasing the availability of this neurotransmitter at the synapse. If the SSRI is effective, the increased serotonin will result in a decrease in symptoms of depression. The other options would not be related to SSRI administration
Which symptom of Parkinson disease has the highest priority for nursing intervention? a. Tremor b. Akathisia c. Dysphagia d. Tardive dyskinesia
C Dysphagia is difficulty swallowing. Because dysphagia can lead to a compromised airway, it is the priority symptom among those listed.
Which medication from a patient's pharmacologic profile is most likely to precipitate neuroleptic malignant syndrome (NMS)? a. Diphenhydramine b. Risperidone c. Haloperidol d. Clozapine
C Haloperidol is a first-generation high-potency antipsychotic drug. It has a greater risk for producing NMS than atypical antipsychotic drugs. Diphenhydramine is not an antipsychotic drug.
A psychiatric nurse should base care of patients diagnosed with Parkinson disease and patients demonstrating extrapyramidal side effects (EPSEs) caused by antipsychotic drug therapy on what premise concerning symptoms? a. Both conditions share similar symptoms. b. Both sets of symptoms result from deficits in dopamine synthesis. c. Both sets of symptoms result from acetylcholine and dopamine imbalance. d. All associated symptoms are produced by neurodegeneration of the substantia nigra.
C In both problems, acetylcholine and dopamine are not in balance. In Parkinson disease, this results from neurodegeneration of the substantia nigra, and in the case of EPSEs, the cause is blockade of dopamine receptors in the basal ganglia. The other options are not valid premises.
Long- and short-term goals are documented in which part of the plan of care? a. Assessment b. Diagnosis c. Outcomes d. Interventions e. Evaluation
C Long- and short-term goals are the product of outcome identification, and documentation is appropriate only in the "outcomes" part of the plan of care.
Which patient receiving antipsychotic medication has the greatest risk for the development of neuroleptic malignant syndrome (NMS) and should be most carefully monitored for this serious adverse reaction? a. One who has a history of hypothermia. b. One with an elevated serum prolactin level. c. One who began treatment with a high-potency drug. d. One whose antipsychotic medication therapy began more than 6 months.
C Neuroleptic malignant syndrome (NMS) is more common among patients receiving high-potency drugs. NMS is associated with hyperthermia and occurs within the first 3 to 9 days of administration. Prolactin levels and NMS are not causally related.
Which medication from the patient's pharmacologic profile would most likely led to the development of neuroleptic malignant syndrome? a. Divalproex sodium b. Amitriptyline c. Haloperidol d. Paroxetine
C Neuroleptic malignant syndrome is more likely to occur in patients taking traditional high-potency antipsychotic drugs. The distracters are not antipsychotic drugs.
The parent of a teen diagnosed with schizophrenia asks, "What is the most likely factor causing this disorder?" The nurse's reply would be based on understanding? a. Glutamate is present in higher than normal quantities resulting in the observable symptoms. b. There is a decrease in norepinephrine causing the basic symptoms. c. There is an increase in dopamine resulting in the classic symptoms. d. A decrease in GABA causes the psychotic symptoms.
C Schizophrenic signs and symptoms are associated with an increase in circulating dopamine. Glutamate is associated with psychotic thinking but not with the other symptoms of schizophrenia. Norepinephrine is related to depression while GABA is a factor in anxiety disorders.
A patient laughs while saying, "My dog died yesterday." The nurse documents this behavior using what terminology? a. Autistic b. Ambivalence c. Inappropriate affect d. Associative looseness
C Speaking of a sad topic while laughing exemplifies inappropriate affect. Autism is characterized by having little concern for external reality. Ambivalence is the simultaneous presence of opposite emotions. Associative looseness is characterized by stringing unrelated topics together.
A highly suspicious patient tells the nurse, "When I sit in the dayroom I can see other people whispering about me and laughing. It makes me want to punch them." What direction should the nurse give staff? a. "Gently and frequently touch the patient while conversing." b. "Stop laughing immediately when the patient enters the room." c. "Be direct. Do not whisper, laugh, or look sideways at the patient." d. "Engage the patient in conversation by leaning close to speak softly."
C Suspicious patients misinterpret the actions of others as being potentially harmful to self. Be direct and open, and avoid behaviors that can be misinterpreted, such as whispering or laughing. In addition, the suspicious patient needs additional personal space. Leaning close is ill-advised. Touching should be avoided because of the high potential for misinterpretation of staff members' motives by the suspicious patient. To stop laughing abruptly when the patient appears would make the individual even more suspicious.
What is the purpose of the DSM-V? a. It provides a detailed list of clinical psychiatric disorders. b. It details data and statistics about mental disorders in the United States. c. It serves as the official American resource manual detailing diagnostic criteria of psychiatric disorders. d. It acts as a compendium of the international demographics of substance abuse and mental disorders.
C The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is published by the American Psychiatric Association. It provides diagnostic criteria for mental and substance abuse disorders and is used throughout the United States. The other options are not descriptive of the DSM-V.
A therapist believes that persons diagnosed with schizophrenia have ego disintegration. This concept is based on which model? a. Biologic b. Interpersonal c. Developmental d. Stress-vulnerability
C The concept of ego disintegration is distinctly freudian. Freud is considered a developmental theorist. This theory is not considered biologic, interpersonal, or stress-vulnerability based.
Which patient receiving fluphenazine should be monitored most closely for extrapyramidal side effects (EPSEs)? a. 35-year-old man b. 45-year-old woman c. 74-year-old woman d. Patient diagnosed with chronic schizophrenia
C Women, older adults, patients with affective symptoms, and patients with first episodes of schizophrenia have a higher risk for EPSEs.
3. Sequence these expressions of suicidality from least to most acute. a. Threat b. Gesture c. Ideation d. Attempt e. Completion
C, A, B, D, E Suicidality exists on a continuum, beginning with ideation and then progressing to threats, gestures, attempts, and finally completed suicide.
A patient taking a psychotropic medication reports, "This medicine isn't working right for me. It's causing side effects." Select the nurse's best comment to further assess the scenario. a. "Has the drug caused diaphoresis?" b. "Have you experienced urinary retention?" c. "Are you experiencing episodes of tachycardia?" d. "Tell me more about how the medication is affecting you."
D Open-ended communication techniques are important strategies for exploring the patient's concerns. It is also important for the nurse to use culturally familiar terms. Patients are unlikely to know the meaning of terms such as tachycardia, diaphoresis, and urinary retention.
A patient tells the nurse, "Air Force jets flying overhead are looking for me. They want to capture me." The patient has not previously verbalized this information. What should the nurse's initial intervention be? a. Set firm limits on disruptive behaviors. b. Forcefully refute all perceptual distortions. c. Encourage complete description of delusions. d. Voice doubt about delusions without arguing.
D A nurse cannot agree with a delusion, but arguing is counterproductive, because it might cause the patient to cling to the idea. Voicing doubt and stating one's own perception of reality is therapeutic. Encouraging discussion of the delusion reinforces it. Because the behavior described is not disruptive, this principle is not relevant.
Genetic evidence regarding twins and the risk for schizophrenia supports which fact? a. Identical and fraternal twins are equal in concordancy for schizophrenia. b. Monozygotic twins have a lower concordancy rate for schizophrenia than the general population. c. Fraternal twins have a higher concordancy rate for schizophrenia than monozygotic twins. d. Monozygotic twins are significantly more likely than the general population to be concordant for schizophrenia.
D Concordancy rates are 50% for monozygotic twins. This rate is 50 times higher than for the general population. The other options are not accurate representations of research data.
9. A patient with low self-esteem and feelings of failure would benefit most from which activity? a. Attending a dance b. Playing board games c. Leading the chorus for a party d. Helping make favors for a party
D Making favors is a productive task that holds little opportunity for failure and ample opportunity for receiving support and positive feedback. The other options hold a greater risk for failure.
A patient who takes a traditional antipsychotic medication says, "I feel shaky and very warm" and is observed to be diaphoretic. The nurse should further assess for what complication? a. Acute dystonia b. Tardive dyskinesia c. Drug-induced parkinsonism d. Neuroleptic malignant syndrome (NMS)
D NMS is a relatively rare but serious reaction to antipsychotic therapy. It is characterized by muscle rigidity, fever, sweating, autonomic instability, altered levels of consciousness, and possible death. The data given in the scenario are not consistent with other options.
The primary mechanisms of action of certain antidepressants result from neurotransmitter inactivation by enzyme-based metabolism and what other event? a. Electrochemical stimulation b. Stimulation of natural precursors c. Extraction of precursors from the bloodstream d. Reuptake into the presynaptic storage vesicles
D Neurotransmitters are inactivated in two ways: (1) they are metabolized by enzymes and (2) they are taken back into the presynaptic storage vesicles—a process called reuptake. The other options have no physiologic basis in fact.
A newly admitted patient is mute, immobile, and holds a fixed body position for long periods. The nurse caring for this patient should implement which intervention? a. Assign unlicensed assistance personnel to feed the patient. b. Provide a stimulating, active environment. c. Encourage independent social behaviors. d. Forewarn the patient before touching.
D Nurses should explain the need for and purpose of touch to patients before actually touching. This is particularly true for patients who are at highest risk for misinterpreting touch—those who are inattentive to reality or those who are suspicious. The environment should be calm and predictable. A patient who is mute and motionless is incapable of independent social behaviors. The patient's oral intake should be monitored, but the correct response also applies to feeding, if it is necessary.
patient who has taken three doses of haloperidol suddenly cries out for help. The nurse observes that the patient's eyes are rolled upward in a fixed gaze. The nurse should document this behavior using what term? a. Akathisia b. Nystagmus c. Tardive dyskinesia d. Oculogyric crisis
D Oculogyric crisis is a specific dystonia in which the eyes roll upward and remain in a fixed position. It results from involuntary muscle spasms and occurs early in the course of treatment. Akathisia refers to motor restlessness. Nystagmus refers to a different type of abnormal eye movements. Tardive dyskinesia refers to abnormal movements primarily of the face and mouth muscles.
A week after beginning fluoxetine, a patient reports, "I still feel so depressed all the time." Based on knowledge of the medication's pharmacodynamics, what is the nurse's most effective intervention? a. Administering the medication when the patient's stomach is empty b. Advising the health care provider that the drug is ineffective. c. Reassessing the expected outcomes of antidepressant therapy d. Educating the patient that the drug needs more time to be effective
D One week is probably an insufficient time for antidepressants to become effective in reducing patient symptoms. The phenomenon of receptor down-regulation develops in 2 to 4 weeks. The other options are not supported by research studies.
When discussing treatment of an aggressive patient diagnosed with psychosis, a health care provider says, "I plan to prescribe the original antipsychotic drug." Which medication is relevant to the statement? a. Paroxetine b. Clozapine c. Imipramine d. Chlorpromazine
D Only chlorpromazine and clozapine are antipsychotics. Chlorpromazine is a traditional drug, introduced in the early 1950s, whereas clozapine is a newer drug, introduced in the 1990s. Paroxetine and imipramine are antidepressants.
What is the priority treatment goal for a patient with severe and persistent mental illness being treated in a community-based facility? a. Formation of new relationships b. Ability to self-administer medications c. Interest in participating in community activities d. Ability to attend to activities of daily living
D Priority outcomes for community treatment focus on the individual being able to function at his or her optimal level by attending to activities of daily living. The other options have a lower priority or can be managed by others.
The nurse reads this information in a patient's record: history of agranulocytosis from antipsychotic medication; victim of childhood sexual abuse; weight loss of 27 lb in 3 months; parent diagnosed with bipolar disorder. Which item would be classified as a psychodynamic factor associated with the patient's mental illness? a. History of agranulocytosis from antipsychotic medication b. Parent diagnosed with bipolar disorder c. Weight loss of 27 lb in 3 months d. Victim of childhood sexual abuse
D Psychodynamic causes of mental illness arise from "nurture"—for example, childhood sexual abuse. The distracters are of biologic ("nature") etiology.
Which assessment finding should be documented as subjective information? a. Flushed face b. White blood cell (WBC) count 12,000 cells/μL c. Lithium level 1.2 mEq/L d. Reports of abdominal pain
D Subjective data are what the patient relates to the nurse such as reports of pain. Objective data are measurable data obtained by the nurse.
8. What is a realistic patient-focused outcome of patient teaching regarding psychotropic medications? a. Understanding physiologic responses to drug therapy b. Assessing effectiveness of prescribed drugs in controlling symptoms c. Describing onset, peak, and duration of action of each drug prescribed. d. Stating the purpose, dose, and significant side effects of each drug prescribed.
D The correct response identifies basic information that each patient should have. Because the information is basic, the outcome, as stated, is realistic. The other options are less basic and less attainable.
A nurse working in an intensive inpatient psychiatric unit should place emphasis on which area of care? a. Behavior modification principles b. Personality restructuring and insight c. Improving interpersonal relationships d. Symptom stabilization and daily living skills
D The nurse will emphasize symptom stabilization and daily living skills, because the length of stay will be short. Behavior modification principles are not used in all settings. Developing insight, restructuring personality, and improving interpersonal relationships are lengthy endeavors.
A patient asks, "Who will be at the community meeting?" How should the nurse responds? a. "Patient representatives and staff" b. "Members of the mental health team" c. "All patients and the nurse manager" d. "All patients, nursing staff, and students"
D Typically, all patients, students assigned to the unit, and all nursing staff attend community meetings. Members of other disciplines might or might not attend.
After an unsuccessful trial with fluphenazine, a patient's medication was changed to trifluoperazine. Three months later the patient is still hallucinating and delusional. What is the most likely explanation for the persistent symptoms? a. Trifluoperazine is a low-potency antipsychotic, and the patient might need higher doses. b. The patient has not taken trifluoperazine long enough to decrease symptoms significantly. c. Delusions and hallucinations are negative symptoms of schizophrenia that do not respond to traditional antipsychotic medications. d. Both fluphenazine and trifluoperazine are traditional antipsychotics, and the patient does not respond well to this class of drug.
D When a trial of a drug produces little change in symptoms and a new drug is to be prescribed, the best plan is to use a drug of another class, because the response to a drug of the first class will usually be poor. The other options are misleading.
What is the primary purpose of a community meeting? a. Making assignments for patients' chores for the day b. Determining patients' eligibility for increases in privileges c. Encouraging patients to share their feelings and individual problems d. Providing a forum for patients to have input into daily program operations
D An emphasis of community meetings is on democratic aspects of unit life. The meeting serves as a forum for patients to voice opinions about the environment and to initiate discussion of community concerns. Making assignments and sharing are only some of the issues addressed in a community meeting. Privilege eligibility would not be discussed in a community meeting.
Which assessment finding should be documented as objective information? a. Rated anxiety 8 on a scale of 10 b. Reported depressed mood c. Reports of headache d. Wore layered clothing
D Objective data are measurable data obtained or observed by the nurse. Layered clothing is an example of objective data. Subjective data are what the patient relates to the nurse.
During a psychiatric emergency, a patient is given a traditional antipsychotic drug intramuscularly and placed in seclusion. Over the next 2 hours, concerns for safety and physiologic stability require that the patient be carefully monitored for what antiadrenergic effect? (Select all that apply.) a. Tardive dyskinesia b. Dystonia c. Drug-induced parkinsonian movements d. Orthostatic hypotension e. Reflex tachycardia.
D, E Hypotension is the major antiadrenergic effect of antipsychotic drugs. It is related to the blocking of alpha1-receptors on peripheral blood vessels, preventing the vessels from constricting automatically to positional changes. Hypotension is frequently noted following intramuscular administration and is of concern because it relates to patient safety and injury from falls. Hypotension also causes a reflex tachycardia that can cause general cardiovascular inefficiency, and jeopardize the patient's physiologic stability. Drug-induced parkinsonian movements, dystonia, and tardive dyskinesia develop over time are not antiadrenergic in mature.
Which guidelines should be included by the nurse who will provide staff development training to unlicensed assistive personnel about psychotherapeutic management? (Select all that apply.) a. Support should be minimal to prevent development of dependence. b. Norms and limits are more important than individual needs. c. Hostility should run its course without staff interference. d. Plan opportunities to strengthen patients' self-esteem. e. Provide encouragement for patients in distress.
D, E Important guidelines include provision of encouragement, especially when patients are in distress, and strengthening patients' self-esteem. The other options are actually the opposite of accepted guidelines.
Which nursing action best supports maintenance of a therapeutic environment? a. Creating therapeutic relationships with patients b. Providing purposeful structured activities c. Maintaining patient records and care plans d. Administering medication
a. Creating therapeutic relationships with patients A therapeutic environment requires nurses to be active and willing to engage in therapeutic relationships with patients. These relationships support patients' development of coping and problem-solving skills. Maintaining records, administering medications, and providing activities are important in the therapeutic environment, but to a lesser extent than meaningful nurse-patient interactions.
Which statement about balance provides a basis for a nurse's management of the therapeutic environment? a. Independence is best gained in increments. b. Independence is a fundamental right of all patients. c. Independence jeopardizes safety in an inpatient setting. d. Dependence is a characteristic of most persons with mental illness.
a. Independence is best gained in increments. Balance is the process of gradually allowing independent behaviors in a dependent situation. Independence must be gained in increments to avoid overwhelming the patient. The distracters are false, since they do not describe the basis of balance.
Which adjective best characterizes custodial care? a. Paternalistic b. Beneficent c. Essential d. Safe
a. Paternalistic Custodial care focuses on activities of daily living, hygiene, nutrition, elimination, and safety needs rather than supporting patients to develop skills for self-care. Staff members decide what is best for patients.
Which research findings about the therapeutic environment of an inpatient psychiatric unit have implications for nursing practice? Select all that apply. a. Patients valued interactions with other patients. b. Patients perceived other patients as dissimilar from self. c. Hospitalization interferes with planning for the future. d. Patients failed to experience bonding with other patients. e. Hospitalization creates feelings of safety from self-destructiveness.
a. Patients valued interactions with other patients. e. Hospitalization creates feelings of safety from self-destructiveness. Findings from the work of Thomas and associates suggest that patients see the hospital as a refuge from self-destructiveness and are fearful of discharge from this safe environment. Furthermore, patients confirmed their identity with other patients (bonding), valued socialization with other patients, and perceived peer-administered therapy as the most valuable aspect of hospitalization.
Which aspects of the environment of a psychiatric unit comply with JCAHO environment-of -care standards? Select all that apply. a. Visitor badges b. Identification badges for employees c. Telephones located in enclosed booths d. Requiring patients to wear hospital-issue clothing e. Guidelines for staff interaction with media representatives.
a. Visitor badges b. Identification badges for employees c. Telephones located in enclosed booths e. Guidelines for staff interaction with media representatives JCAHO standards mandate clothing suitable for the clinical environment, but they do not require patients to wear hospital-issue clothing. The other answers comply with standards.
During a community meeting, a patient reports about having only two patient-accessible phones on the unit. Many other patients join in, all talking at the same time. The nurse requests that only one person talk at a time. The nurse's request seeks to maintain: a. norms. b. safety. c. balance. d. structure.
a. norms. Norms establish expectations that promote safety and trust in a therapeutic environment through sanctioning of socially appropriate behaviors. The other elements cannot be assessed as related to the scenario.
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards mandate that: a. orientation programs detail safety issues and precautions. b. patients' room doors remain open during hours of sleep. c. safety precautions are simple and apply commonsense behaviors. d. patients' personal belongings are kept in secure areas under staff control.
a. orientation programs detail safety issues and precautions. JCAHO standards require agencies to provide an orientation program that addresses safety
The framework of schedules, rules, and activities around which a therapeutic environment revolves is termed: a. structure. b. balance. c. norms. d. safety.
a. structure. Structure refers to the physical environment, regulations, and daily schedule of classes and groups provided in a treatment setting. Structure provides the base on which the other elements are built.
Which statements indicate that a patient understands the unit norms? Select all that apply. a. "I need quiet time after art therapy today." b. "I will not yell during the community meeting." c. "I realize that I need help with my problems." d. "I will show up on time to take my medication." e. "I will talk to staff if I get angry instead of punching somebody."
b. "I will not yell during the community meeting." d. "I will show up on time to take my medication." e. "I will talk to staff if I get angry instead of punching somebody." Norms are specific expectations of socially acceptable behavior intended to promote community living, such as behaving with civility during a community meeting, behaving in nonviolent ways, maintaining personal control, and accepting personal responsibility. The correct options are desirable behaviors related to norms rather than individual treatment goals.
2. Four nurses describe their unit environments. Which description can most clearly be identified as therapeutic? a. "My unit uses behavior modification to enhance patients' social skills." b. "My unit allows patients to test new behaviors in a secure environment." c. "My unit helps patients deal with childhood issues by providing a safe setting." d. "My unit allows patients to deal with personal issues without interpersonal stressors."
b. "My unit allows patients to test new behaviors in a secure environment." The unit described in the correct answer provides a broad therapeutic focus for providing corrective experiences that helps patients recover. The distracters are too narrow in their therapeutic scope.
5. Which nursing action best supports the maintenance of psychologic safety for a patient with mental illness? a. Helping a depressed patient to inventory personal flaws b. Assisting a patient to change clothes after an episode of incontinence c. Allowing an anxious patient to pace in isolation and without interruptions d. Requiring a restrained patient to remain silent until restraints are removed
b. Assisting a patient to change clothes after an episode of incontinence Assisting a patient to change clothes after an episode of incontinence saves embarrassment for the patient, which contributes to a positive self-concept. Requiring a restrained patient to remain silent implies punishment rather than use of an external control until they are able to regain control. The other options are not therapeutic and do not promote psychologic safety.
While nurses are engaged in shift change report, one patient becomes loud and aggressive. This patient verbally harasses and frightens another patient. Which element of the therapeutic environment has been jeopardized? a. Norms b. Safety c. Balance d. Structure
b. Safety Psychologic safety is violated when one patient is allowed to harass another. Staff must set limits to protect the vulnerable patient. Norms, balance, and structure refer to other elements of the environment.
The nurse leading a social skills group is engaged in managing which environmental element? a. Balance b. Structure c. Accountability d. Risk management
b. Structure By definition, the element of structure includes the schedule of planned therapeutic activities and groups. Balance refers to dependence-independence behaviors. Accountability and risk management are not identified elements of the therapeutic environment.
In which instance would it be most important for the nurse to set limits? a. An involuntarily hospitalized patient insists on being discharged. b. Two patients are found kissing in an obscure area of the unit. c. A patient with suicidal ideation asks to leave the unit. d. A depressed patient seeks daily telephone privileges.
b. Two patients are found kissing in an obscure area of the unit. Limits should be set on acting-out behavior, self-destructive acts, physical aggressiveness, sexual behavior, lack of compliance, use of illicit substances, and elopement. The correct answer is an example of sexual behavior. The distracters depict instances in which a therapeutic response is indicated from the nurse but not necessarily limit-setting.
Complete the sentence. In a therapeutic environment, norms are: a. opportunities for self-expression that relieve stress. b. expectations for socially acceptable behavior. c. the behaviors most people display daily. d. shared experiences among patients.
b. expectations for socially acceptable behavior. Norms are defined as specific expectations of behavior that pervade a setting. They are intended to promote community living through socially acceptable behaviors. The other explanations are not as comprehensive as the correct answer.
A patient has been bumping and pushing other patients. The nurse carefully explains to the patient that such behavior is unacceptable. The nurse has provided: a. balance. b. limit-setting. c. personal control. d. environmental modification.
b. limit-setting. Limit-setting provides a patient with a clear explanation of the acceptability or unacceptability of a behavior. Limit-setting reinforces norms and encourages the milieu concept of responsibility for self. The other options are not applicable.
6. Which element of therapeutic environmental management has the highest priority? a. Clearly establishing norms and designating limits b. Scheduling purposeful activities throughout the day c. Creating an environment of psychologic and physical safety d. Promoting a balance between patient dependence and independence
c. Creating an environment of psychologic and physical safety Safety is the most basic milieu element and therefore is of highest priority. Norms often contribute to safety. Activities and balance are other important milieu elements but are of lower priority.
A newly admitted patient is withdrawn and does not seek out interaction with staff or patients. Nursing interventions should focus on which element of the treatment environment? a. Norms b. Safety c. Structure d. Limit-setting
c. Structure Structure refers to the physical environment, regulations, and daily schedule of classes and groups provided. The unit activities will provide an opportunity for the nurse to interface with the patient to develop a trusting relationship. The other treatment environment elements are important but are of lower priority for this patient.
During orientation the clinical nurse leader tells a novice nurse, "You will be involved in purposeful creation of corrective learning experiences for all patients so as to provide a healing atmosphere." The clinical nurse leader is explaining aspects of: a. balance. b. limit-setting. c. a therapeutic environment. d. establishing behavioral norms.
c. a therapeutic environment. A therapeutic environment requires creation of corrective learning experiences to promote a therapeutic atmosphere. Limit-setting, balance, and norms are individual elements of the therapeutic environment and are answers that are too narrow.
A patient demonstrating manic behaviors gathered other patients in the dayroom and gave a sales talk, pressuring others to purchase shares of stock in a gold mine. Which element of a therapeutic environment is jeopardized? a. Connection b. Exploration c. Structure d. Balance
d. Balance The patient is violating the rights of others by being allowed to give unsolicited discourses and exert pressure on others. Balance is lacking when patients are not protected from the symptom expression of other patients.
A psychiatric facility is "accredited by JCAHO." Which asset would be expected? a. A 4:1 patient-to-staff ratio b. Private rooms for all patients c. Use of a therapeutic milieu treatment model d. Telephones for private patient conversations
d. Telephones for private patient conversations JCAHO environment-of-care standards stipulate that telephones must be available to allow patients to conduct private conversations. The other options are not specified in JCAHO standards.
A nurse plans ways to promote patient safety and security. A proactive approach would include: a. restricting psychotic patients' rights. b. enforcing consequences of limit-setting. c. setting limits when a patient acts out aggressively. d. clearly communicating expectations for patients' behavior.
d. clearly communicating expectations for patients' behavior. Proactive is the key word in this question. Communicating clear rules for expected behavior from the beginning reinforces norms and structure, and encourages self-responsibility. The other options are reactive.
