Psych Final - Cumulative Set
most prevalent mental disorder
anxiety
7. A parent is admitted to a chemical dependency treatment unit, where the patient's spouse and adolescent children participate in a family session. What is the most important aspect of family function to be initially assessed? a. Spouse's co-dependent behaviors b. Interactions among family members c. Patient's reaction to the family's anger d. Children's responses to the family sessions
ANS: B Interactions among all family members are the raw material for family problem-solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are too narrow in scope when compared with the correct option.
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.
8. A parent is admitted to a chemical dependency treatment unit. The patient's spouse and adolescent children attend a family session. What is the priority assessment question to ask family members to best assess family unit characteristics? a. "What changes are most important to you?" b. "How are feelings expressed in your family?" c. "What types of family education would benefit your family?" d. "Can you identify a long-term goal for improved functioning?"
ANS: B It is important to understand family characteristics in both the family of origin and the present family. The other questions are related more to outcome identification and planning intervention, neither of which should be attempted until assessment is complete.
5. A patient's haloperidol dosage was reduced 2 weeks ago to decrease side effects. What assessment question demonstrates the nurse's understanding of the resulting needs of the client? a. "Will you have any difficulty getting your prescription refilled?" b. "Have you begun experiencing any forms of hallucinations?" c. "What do you expect will occur since the dosage has been reduced?" d. "What can I do to help you manage this reduction in haloperidol therapy?"
ANS: B It will be necessary for the nurse to assess for exacerbation of the patient's symptoms of psychosis as well as for a lessening of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming. While the other options may be appropriate assessment questions, they are not directed at the current needs of the client; the identification of emerging psychotic behaviors.
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.
2. Select the accurate information about the pharmacokinetics of lithium. a. Wide therapeutic index b. Excreted by the kidneys c. Poorly absorbed in the gastrointestinal (GI) tract d. Provides immediate relief of symptoms
ANS: B Lithium is excreted via the kidneys. The other options are incorrect. The nursing implication is that individuals with renal damage should not be given lithium or should be monitored closely if lithium must be administered.
15. What assessment data supports the possibility that the sexual abuse is incestual in nature? a. The abuse began when the client was 10 years old. b. The abuser was the client's uncle. c. The client's parents were aware that the abuse occurred. d. The abuse involved only fondling.
ANS: B Sexual abuse can involve anyone as the abuser, but incest refers to a family member. None of the other options sufficiently demonstrate the criteria required of incest.
5. A desired outcome for a 12-year-old diagnosed with autism spectrum disorder (ASD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Social skills group c. Response prevention d. Insight-oriented group therapy
ANS: B Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser to no impact on peer relationships.
3. A patient is recovering from surgery to remove a tumor in the cerebellum. Which assessment finding is most attributable to this diagnosis? a. The patient reports of limited taste and smell. b. The patient demonstrates poor balance and coordination. c. The patient has limited ability to learn and poor memory. d. The patient has poor emotional control and low motivation.
ANS: B The cerebellum coordinates muscle synergy and is responsible for the maintenance of equilibrium. The limbic system plays a role in taste, smell, memory, learning, emotional control, and motivation.
A patient has had long-term conflicts with two siblings over their parents' wills. The patient reacts quickly with anger, suspicious that the siblings are plotting to take all the inheritance. These characteristics are most consistent with which personality disorder? a. Schizoid b. Paranoid c. Borderline d. Narcissistic
ANS: B The characteristics mentioned in the scenario fit the description of paranoid personality disorder. Schizoid personality is characterized by shyness, withdrawal, and poor social relationships. Borderline personality is characterized by problems with identity, self-image, mood, and impulsivity. Narcissistic personality is characterized by self-importance, grandiosity, and a sense of entitlement.
19. Which statement, made by a new psychiatric nurse, best describes the therapeutic use of self? a. "Most nurses have caring personalities that equip them to be helpful to patients." b. "It's mostly about using good verbal and nonverbal communication, objectivity, genuineness, and empathy." c. "It means that you keep yourself at a distance so you are not affected by patients' problems and emotions." d. "The most important aspect of practice is when and how much to touch, as well as when to listen and give advice."
ANS: B The correct answer lists several of the components of therapeutic use of self. The other options provide less information for the new nurse to use to continue to develop skills.
14. A patient diagnosed with major depression shows the nurse a passage in the Bible and says, "How do you think this verse relates to me?" The nurse is unfamiliar with the verse and unsure how to respond. Select the nurse's best action. a. Ask the patient, "What do you think the verse means?" b. Invite professional clergy to join the dialog with the patient. c. Explain to the patient, "I'm not familiar with that passage. It would be better for me not to comment." d. Say to the patient, "Would you bring that up in the group session? You can get input from several people about what the verse means."
ANS: B The correct answer shows that the nurse recognizes personal limits but remains engaged in the interaction with the patient. The distracters reject the patient's concerns.
2. Which social event would likely be most disturbing for this soldier diagnosed with PTSD? a) Halloween festival with neighborhood children b) Picnic and fireworks display on July 4th c) Singing carols around a Christmas tree d)A family outing to the seashore
ANS: B The exploding noises associated with fireworks are likely to provoke exaggerated responses from this soldier. The distracters are not associated with offensive sounds.
16. A patient diagnosed with bulimia nervosa has not responded to psychotherapeutic management. The health care provider is likely to prescribe a drug from which classification? a. Mood stabilizer b. Selective serotonin reuptake inhibitor (SSRI) antidepressant c. Typical antipsychotic d. Monoamine oxidase inhibitor antidepressant
ANS: B There is some evidence that SSRIs might be effective as adjunctive treatment of bulimia. The other drugs would not be considered appropriate.
The sibling of a depressed patient says, "When we were children, my sister always gave up easily. Now as an adult, everyone in the family takes advantage of her." What is the most appropriate nursing intervention? a. Begin cognitive therapy to reduce negative thinking. b. Plan measures to reduce inappropriate feelings of guilt. c. Discuss the value of assertiveness training with the patient. d. Invite the sibling to join the patient's group therapy sessions.
ANS: C Depressed patients often allow people to violate their rights, and then feel resentful or angry. Assertiveness training will help the patient change her interpersonal style from acquiescent to assertive and reduce resentfulness. Cognitive therapy and working on guilt feelings will not address the passive behavior. It would not be appropriate to include the sibling in the patient's group therapy.
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.
13. What is a common mistake nurses make when developing therapeutic communication techniques? a. Using too many different techniques during an interaction b. Allowing patients to become too anxious before responding c. Giving advice rather than encouraging patients to solve problems d. Focusing on what patients say rather than on communication techniques
ANS: C Giving advice is a common pitfall for nurses who are unsure of how to encourage patients to become involved in analyzing and problem-solving. The other options are incorrect, because most novice nurses tend to rely heavily on direct questions, avoid anxiety-producing topics, and focus on communication techniques.
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.
15. What assessment question should the nurse ask to assess a family's ability to cope? a. "What strengths does your family have?" b. "Do you think your family copes effectively?" c. "Describe how you successfully handled one family problem." d. "How do you think the current family problem should be resolved?"
ANS: C The correct option is the only statement addressing coping strategies used by the family. The other options seek opinions or are closed-ended.
When communicating with a depressed patient with psychomotor retardation, the nurse should: a. communicate using yes/no questions. b. avoid asking for the patient's preferences. c. be prepared to wait for the patient to respond. d. encourage the patient to nod if speaking is too difficult.
ANS: C The patient with psychomotor retardation has slowed thinking and speech, pauses before responding, and uses few words. The nurse should avoid hurrying and/or seeming impatient when interacting with the patient. Allow ample time for the patient to formulate a response and articulate it. The other interventions would be nontherapeutic.
The history of an individual diagnosed with borderline personality disorder often includes: a. the loss of a parent at an early age. b. a family history of bipolar disorder. c. a dysfunctional, abusive childhood. d. an overindulged childhood with few limits.
ANS: C There is no clear-cut cause for borderline personality disorder. It is probably multifactorial. Environmental factors include childhood neglect and abuse. Biologic theories suggest neurotransmitter dysregulation. Object losses, family history of bipolar disorder, and overindulgence as a child have not been identified as causative facto
4. A patient has taken lithium (Lithobid) 300 mg three times daily for 1 week. The patient reports the presence of fine hand tremors and thirst. Select the nurse's best action. a. Increase sodium in the patient's diet. b. Immediately obtain a serum lithium level determination. c. Comfort the patient that these effects will probably decrease over time. d. Withhold the lithium until the patient no longer exhibits these side effects.
ANS: C These side effects are common and often decrease or disappear over time with continued lithium therapy. Dietary sodium should remain unchanged to keep the lithium level stable. These side effects do not suggest the need for determination of a lithium level. Lithium should not be withheld, because these are not toxic symptoms.
20. A patient comes to the clinic for the fifth time in a month with vague complaints of not feeling well. The nurse notices fresh bruises on the patient's upper body. Which assessment question should take priority? a. "How much do you drink each day?" b. "Are you annoying to anyone?" c. "Did anyone hurt you?" d. "Have you fallen?"
ANS: C When the nurse suspects abuse, it is appropriate to speak directly to the issue. Two distracters are presumptuous and blaming. The other distracter offers a ready-made excuse for the bruises.
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.
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.
MULTIPLE RESPONSE 1. A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply. a) Schizophrenia b) Eating disorder c) Traumatic brain injury d) Seasonal affective disorder e) PTSD
ANS: C, E TBI and PTSD each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distracters would be expected to parallel the general population.
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. An adult diagnosed with chronic depression is hospitalized after a suicide attempt. Which intervention is critical in assuring long-term, effective client care as described by psychotherapeutic management? a. Involvement in group therapies b. Focus of close supervision by the unit staff c. Maintaining effective communication with support system d. Frequently scheduled one-on-one time with nursing staff
ANS: D A critical element of psychotherapeutic management is the presence of a therapeutic nurse-patient relationship. One-on-one time with nursing staff will help in establishing this connection. While the other options are appropriate and client centered, the nurse-client relation is critical in the long-term delivery of quality effective care to this client.
15. What assessment finding supports a diagnosis of anorexia rather than bulimia? a. Body weight near normal for height b. Fluid and electrolyte imbalances are present c. Engages in strenuous exercise daily d. Eating disorder begin at age 14
ANS: D Anorexia tends to begin at an earlier age than bulimia. Engaging in strenuous exercise can occur in both disorders. The other options related to bulimia rather than anorexia.
14. Before beginning lithium therapy, the nurse should educate a patient about laboratory tests to assess for adequate function of which system? a. Peripheral vascular b. Reproductive c. Respiratory d. Renal
ANS: D Because lithium is excreted via the kidneys, renal system function must be adequate if lithium toxicity is to be prevented. Functioning of the other systems has no direct relationship to lithium therapy.
2. When observing and interpreting a patient's nonverbal communication, which nursing consideration is important? a. Knowing that patients are usually aware of their nonverbal cues b. Accepting that verbal responses are more important than nonverbal cues c. Recognizing that nonverbal cues have obvious meaning and are easily interpreted d. Validating nonverbal cues to provide significant information
ANS: D Body language has meaning, but meaning cannot be globally ascribed. Validation with the individual is necessary to accurate interpretation. The other options are incorrect in the information they provide.
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.
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.
17. A patient has become verbally abusive toward their spouse and oldest child since losing a job 6 months ago. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family? a. Impaired parenting, related to verbal abuse of oldest child b. Impaired social interaction, related to disruption of family bonds c. Ineffective individual coping, related to fears about economic stability d. Disabled family coping, related to insecurity secondary to loss of family income
ANS: D Disabled family coping refers to the behavior of a significant family member that disables his or her own capacity as well as another's capacity to perform tasks essential to adaptation. The distracters are inaccurate because more than one individual is affected by the stressors.
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.
14. A nurse in a community mental health center receives a call asking for information about a patient. Under which condition can the nurse release information to the caller? a. The caller is related to the patient. b. The psychiatrist approves the request. c. The caller is a mental health professional. d. The patient has given written consent for release of information.
ANS: D Patient information is privileged. Information cannot be released without consent signed by the patient. None of the other conditions meet that criteria.
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.
4. Which information is the nurse most likely to find when assessing the family of a patient with a serious and persistent mental illness? a. The family exhibits many characteristics of dysfunctional families. b. Several family members have serious problems with their physical health. c. Power in the family is maintained in the parental dyad and rarely delegated. d. The stress of living with a mentally ill individual has negatively affected family function.
ANS: D The information almost universally obtained is that the family is under stress associated with having a mentally ill member. This stress lowers the family's level of functioning in at least one significant way. Stress does not necessarily mean the family has become dysfunctional.
18. A patient says, "It's my fault because I always make bad decisions. I should never have taken that job." Using a rational-emotive approach, how would the nurse respond? a. "What can you do to help yourself solve your problems at work?" b. "You're experiencing a great deal of stress right now. How can you manage it more effectively?" c. "Can you describe a time in your childhood when your parents blamed you for things you didn't do?" d. "Consider the words you are using to talk about yourself. Let's try to change those words to more positive ones."
ANS: D The therapist using rational-emotive therapy helps the patient identify irrational thoughts and replace them with new, more positive self-statements to enable the patient to think, feel, and behave differently. The other options do not make use of the combination of cognitive, emotive, and behavioral components.
10. Which finding indicates that a patient diagnosed with anorexia nervosa has met a major objective of psychotherapeutic management? a. The patient's residual volume is less than 30 mL before tube feedings. b. The patient says, "I am no longer fearful of gaining weight." c. The patient reads cookbooks and plans nutritious meals. d. The patient weighs 90% of average body weight.
ANS: D The three objectives are increasing self-esteem, increasing weight to 90% of average body weight, and re-establishing appropriate eating behavior. Reading cookbooks or planning nutritious meals may be evidence of manipulation. A low residual volume simply indicates that the patient is utilizing the feedings and there is no intestinal obstruction. Lack of fear does not translate to proper eating or an improved self-esteem.
1. Which skill is most important for a nurse preparing to work in the psychiatric setting? a. Helpful transference b. Sympathetic listening c. Supportive confrontation d. Therapeutic communication
ANS: D Therapeutic communication provides the basis for effective use of each stage of the nursing process, as explained by the authors. The other options are skills basic to effective use of the nursing process.
4. After attending a group, which statement by a patient shows evidence of benefits associated with universality? a. "I've learned to identify my anxious feelings." b. "The group really gave me the support to change." c. "I've learned that I can be helpful to others." d. "My problems are not unique. I'm not alone."
ANS: D Universality refers to patients' realization that they are not alone and unique, and that others experience similar problems, feelings, and concerns. The remaining options do not reflect that sense of belonging.
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.
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.
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 tricyclic antidepressant (TCA) is prescribed for a patient newly diagnosed with depression. What information should be included in patient teaching? a. "Take this medication on an empty stomach." b. "Do not eat aged cheese while using this medication." c. "You might experience sweating, tremors, and excessive urination." d. "It might be 2 weeks or more before you notice the effects of this medicine."
D Antidepressant effects might take several weeks to be noticeable. Avoidance of tyramine (as is present in aged cheeses) is necessary for monoamine oxidase inhibitors (MAOIs) therapy but not for TCAs. It is not necessary to take TCAs on an empty stomach. Sweating, tremors, and urination problems are not commonly experienced with TCA therapy.
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.
A depressed patient preparing for discharge is prescribed desipramine and will have follow-up outpatient visits. The patient reports, "Why did they gave me only a 1-week supply of my medicine?" Select the nurse's best reply. a. "Federal law limits the amount you may be given at any one time." b. "It will save you money if the drug doesn't work well for your symptoms." c. "This is a way of ensuring that you will come in for your follow-up appointment." d. "Prescribing a small amount of drug addresses our concerns for your continuing safety."
D Desipramine is an activating antidepressant, and it might provide a patient who has suicidal ideation with the energy to make an attempt. Because the therapeutic dose and lethal dose are not widely separated, tricyclic antidepressants (TCA) overdose is an often-used suicide plan. Because desipramine appears to be the most toxic TCA, prescribing only a 7-day supply limits the possibility of using the drug in a suicide attempt. The other options are either less relevant or incorrect.
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 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.
Psychological tests
Evaluation tools that objectively measure personality, intelligence, and symptoms of mental illness.
Spirituality is best defined as A. organized religion that is practiced weekly B. agnosticism and atheism C. that which displaces an expression of religion D. motivation, strength, meaning and connectedness to self and others
Spirituality is best defined as D. motivation, strength, meaning and connectedness to self and others
Suicidal thoughts
The thought, threat, plan, or intent for self-destruction.
student grumbles to an instructor, "I do not see the value of process recordings." The best justification of a process recording is that it is a: a. tool for analyzing communication. b. verbatim record of a patient interview. c. legal document that becomes part of the medical record. d. note written at the time of a patient interview to provide information to team members.
a. tool for analyzing communication.
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.
concept of recovery model
can't cure, can help manage and live as independently as possible in least restrictive setting
Which statement demonstrates empathy on the part of the nurse responding to a patient who is angry about the death of her child? a. "I lost a child too, so I know how you feel." b. "It is a pity that someone so young was taken from you." c. "You have a right to be angry, losing a child is so unfair." d. "It's normal to be angry, but let's talk about how to handle that anger."
d. rationale: Empathy is an objective understanding of the way in which patients see their situation. It can also convey hope for improvement. Sympathy, by contrast, is the nurse having the same feelings as the patient, and objectivity is therefore lost. Sympathy often leads to comforting, reassuring, or pitying patients.
A patient diagnosed with schizophrenia says to the nurse, "I feel really close to you. You're the only true friend I have." Select the nurse's most therapeutic response. a. "We are not friends. Our relationship is a professional one." b. "I feel sure there are other friends in your life. Can you name some?" c. "I am glad you trust me. Trust is important for the work we are doing together." d. "Our relationship is professional, but let's explore ways to strengthen friendships."
d. "Our relationship is professional, but let's explore ways to strengthen friendships."
Which ethnic group has a worldview where knowledge is acquired through proof that something exists? This proof is acquired through the ability of an individual to see, hear, touch, taste, or smell it. 1 European-American 2 Arabic 3 Asian 4 Native American
1 According to the European-American worldview, knowledge is acquired according to proof of the existence of anything—that is, the ability of an individual to see, hear, touch, taste, or smell it. The Arabic worldview holds that knowledge bases are developed through the use of the affective or feeling senses. According to the Asian worldview, knowledge bases are developed in striving for transcendence of the mind and body. Native Americans believe that knowledge bases are developed on the basis of a person's understanding of an individual's relationship with the Greater or Supreme Being. DIF: Cognitive level: Understanding REF: p. 51 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
When assessing a patient of a racially or ethnically diverse group regarding the use of alternative therapies, which question will the nurse ask? 1 "What do you think will make you feel better?" 2 "Do you believe in folk healers?" 3 "How long have you been ill?" 4 "Can you tell me about your spiritual beliefs?
1 Asking about past medical practices begins an assessment and determines the use of complementary and alternative therapies, and opens an opportunity for the patient to speak about other healing, wellness, or health options. Directly asking a closed-ended question about a belief may challenge the patient. While asking when the illness began is an act-based question, it is not related to alternative therapies. A general question concerning spiritual belief is too broad and may not assess for use of alternative therapies. DIF: Cognitive level: Applying REF: p. 54 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
Which statement is true when comparing today's mentally ill patients with those observed in the 1960s and 1970s? 1 In the 1960s and 1970s, the primary mental health diagnosis was depression. 2 Today's patients are more aggressive and often armed when seen on initial assessment. 3 Today there are more people hospitalized with mental illness than in the 1960s and 1970s. 4 Jails and prisons house fewer mentally ill persons today than during the 1960s and 1970s.
2 Compared with the patients of the 1960s and 1970s, today's patients are more aggressive and many are armed when first seen. Depression was not necessarily the primary mental health diagnosis during the 1960s and 1970s. The hospital population peaked in 1955 and has declined steadily to this day. Today there are 300% more patients with severe mental illness in jails and prisons than there are in hospitals in the United States; these numbers have increased steadily over the last several decades.
When supporting an individual's spirituality, what is assessment question will the nurse ask? 1 "Which church do you attend?" 2 "Are you a religious person?" 3 "Would you like a consult with the chaplain?" 4 "What spiritual needs do you have right now?"
4 Asking the patient to identify their spiritual needs using an open-ended question begins the assessment process. This question is inclusive of a variety of belief systems while honoring and respecting the individual's values and acknowledging spiritual needs. It is inappropriate to assume an individual attends a church. Asking if the person is religious is a closed-ended question and can be viewed negatively by the person. Asking whether a chaplain consult is desired is a closed-ended question that proffers the nurse's values and can be considered as disrespectful by the individual. DIF: Cognitive level: Applying REF: p. 57 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
Who introduced the terms psychoanalysis, id, ego, superego, and free association into today's psychiatric language? 1 Otto Rank 2 Helene Deutsch 3 Karen Horney 4 Sigmund Freud
4 Sigmund Freud introduced terms that have become part of our language: psychoanalysis, id, ego, superego, and free association. Although the other scientists listed made contributions to modern psychiatry, they were not responsible for these terms.
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.
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.
11. A man tells the nurse, "I have trouble maintaining an erection." This comment indicates which possible sexual disorder? a. Erectile disorder b. Desire disorder c. Pain disorder d. Orgasm disorder
ANS: A In sexual erectile disorders, the individual cannot maintain the physiologic requirements for sexual intercourse. The patient's statement does not provide data to suggest one of the other options.
1. Maintenance of a therapeutic serum level of lithium is dependent on adequate serum levels of: a. sodium. b. chloride. c. potassium. d. magnesium.
ANS: A It is believed that lithium substitutes for the sodium (Na) ion in neurons. Reductions or increases in Na intake affect the serum lithium level. The other options have not been identified as critical to lithium level.
10. A Hispanic patient says, "I have no energy and cannot eat. I want to sleep but can't, because pain moves around different parts of my body." A physical examination reveals no pathology. The nurse should hypothesize that the patient may be experiencing which culturally bound illness? a. Lost soul (susto) b. Spiritual distress c. A broken heart d. Amok
ANS: A Loss of one's soul, a culture-bound illness occasionally seen among Hispanic individuals, produces vague symptoms such as those described. Western medicine regards these as depressive symptoms, but individuals with lost soul speak only of physical symptoms, rather than psychological or emotional disequilibrium. The other options are culture-bound disorders with symptoms different from what is described in this scenario.
6. Which statement by a mentally ill patient best exemplifies sick religiosity? a. "Suicide will result in eternal damnation for your soul." b. "Your illness has nothing to do with insufficient faith." c. "Questioning God is a common reaction to illness." d. "Your illness is not related to sin."
ANS: A Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The correct option best exemplifies this thinking. The other options are supportive of the patient's spirituality.
Which characteristic of individuals diagnosed with personality disorders in the dramatic-erratic cluster makes it advisable for staff to have frequent patient-centered meetings? a. Manipulating others to avoid limits b. Behaving responsibly in the peer group c. Withdrawing from interactions with others d. Depending excessively on others for support
ANS: A The group of dramatic-erratic personality disorders includes antisocial and borderline personality disorders. These patients are particularly skillful at manipulating others to get their needs met. The distracters list characteristics that would not require frequent meetings
14. Parents of a mentally ill teenager say, "We've never known anyone who was mentally ill. We have no one to talk to because none of our friends understand the problems." What intervention by the nurse would be most helpful in meeting the parent's expressed need? a. Referring the parents to a family support group b. Building their self-esteem as coping parents c. Teaching techniques of therapeutic communication d. Facilitating achievement of normal developmental tasks
ANS: A The need for support can be clearly identified. Referrals are made when working with families whose needs are unmet. A support group such as the National Alliance for the Mentally Ill (NAMI) will provide these parents with the support of others who have had similar experiences and with whom they can share feelings and experiences. The distracters are less relevant to their need to interact with others parenting a mentally ill teen.
10. Two divorced people plan to marry. The man has a teenager, and the woman has a toddler. This family will benefit most from what form of counseling? a. Guidance about parenting at two developmental levels. b. Role-playing opportunities for conflict resolution. c. Formal teaching about problem-solving skills. d. Referral to a family therapist with divorce counseling experience.
ANS: A The newly formed family will be coping with tasks associated with the stages of rearing preschool children and dealing with teenagers. These stages require different knowledge and skills. There is no evidence of a problem, so the distracters are not indicated.
12. The spouse of a patient diagnosed with bipolar I disorder says, "We want to have children, but I worry they could inherit this problem. There is also bipolar disorder on my side of the family." What is the nurse's most appropriate action? a. Direct the couple to seek genetic counseling. b. Encourage the couple to consider adopting children. c. Encourage the spouse to discuss options with a spiritual advisor. d. Educate the spouse about environmental determinants of bipolar disorder.
ANS: A The nurse's advice should be based on knowledge that there appears to be a genetic role in the cause of bipolar disorder. Genetic counseling will provide the couple with the best possible basis for decision making. The other options will not provide the information that the couple needs to make an informed decision.
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. 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.
1. A nurse teaching about bipolar disorder should inform patients and their families of possible depressive symptoms. Which symptoms should the nurse include? Select all that apply. a. Passivity b. Aggression c. Hyperactivity d. Psychomotor retardation e. Preoccupation with death
ANS: A, D, E The symptoms of a bipolar depressive episode are often atypical, such as those consistent with the atypical depressive symptoms of major depressive disorder. They include preoccupation with death, psychomotor retardation, and passivity.
18. A patient who is admitted involuntarily with a diagnosis of bipolar disorder, manic phase, refuses a prescribed dose of lithium. The nurse assembles a show of force and intimidates the patient into taking the medication. What is a likely an outcome of this action for the patient? a. A lessening of mania b. Grounds for a civil suit against the nurse for assault c. Grounds to sue the hospital for false imprisonment d. Improved nurse-patient relationship
ANS: B A nurse who forces a patient to accept treatment or take medication in a nonemergency situation against the patient's wishes can be found liable for assault (threatening) and battery (nonconsenting touching) in civil court, even if the nurse had the best interest of the patient in mind. Such action would not serve to improve the nurse-patient relationship. Diminished symptoms of mania are not likely to be related to a single dose of lithium. The scenario does not describe the conditions of false imprisonment. Actions taken in the best interest of the patient that violate the patient's rights are cause for civil action.
7. When the nurse conducts a developmental assessment with a new patient, the assessment can be expected to yield information regarding what patient characteristic? a. The use of defense mechanisms b. The degree of mastery of critical tasks c. Strategies to help the patient make rational decisions d. The mobilization of defenses against the patient's stressors
ANS: B According to Erikson developmental theory, a developmental assessment is conducted for the purpose of determining the extent to which an individual has successfully mastered the critical task of each stage of development up to his or her chronologic age. Lack of mastery or partial mastery will yield clues about issues to be addressed in working with the patient. Because of its focus, the developmental assessment might yield only minimal information about defense mechanism use and defenses used to cope with stress. Rational decision making is not expected to be fostered as a result of developmental assessment.
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.
1. A patient living in community housing for older adults says, "I don't go to the senior citizens club. They play cards and talk about the past, because that's all they can do." The nurse suspects that these remarks represent what personal behavior? a. Failure to achieve developmental tasks b. Thinking associated with ageism c. Hypercritical behavior d. Paranoid thinking
ANS: B Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of using ageism as younger individuals. The other options are not substantiated by the information given in the scenario.
10. A 65-year-old patient is diagnosed with late-onset schizophrenia. Both positive and negative symptoms of the disorder are present. The patient has a history of atrial fibrillation. The nurse should prepare patient education materials related to what medication? a. Chlorpromazine b. Risperidone c. Thioridazine d. Haloperidol
ANS: B Atypical antipsychotics such as risperidone are effective against both positive and negative symptoms of schizophrenia and have the most favorable side effect profile. The distracters are typical antipsychotics. Chlorpromazine and thioridazine may cause cardiovascular side effects. Haloperidol may cause neurologic side effects.
18. An acutely psychotic patient is restricted to an inpatient unit. This intervention demonstrates that which milieu element has been adapted? a. Norms b. Balance c. Therapy d. Psychopathology
ANS: B Balance refers to negotiating the line between dependence and independence. The more psychotic the individual, the less independence he or she can usually handle safely. Unit restriction with careful supervision by staff helps compensate for lack of patient judgment. Norms refers to behavioral expectations for patients. Therapy is provided by advanced-practice nurses or others with advanced education and so is not an element of milieu management. Psychopathology is not considered an environmental element.
8. What high priority assessment should a nurse caring for an older adult who self-administer medications preform? a. Use of stimulants b. Overuse of benzodiazepines c. Misuse of antihypertensive medications d. Trading medications with acquaintances
ANS: B Benzodiazepines are among the most widely prescribed medications. They are often prescribed in high doses and for prolonged periods, leading to tolerance, physical dependence, and psychological dependence. The other options are relevant but are not of the highest priority.
The plan for a depressed patient includes use of cognitive therapy. The nurse supports this therapy by: a. uncovering unconscious conflicts by encouraging description of childhood traumas. b. challenging pessimistic beliefs and recognizing the patient's accomplishments. c. determining areas of mutual understanding between the nurse and patient. d. using role playing to rehearse new behaviors.
ANS: B Depressed patients evaluate situations as being negative. Cognitive therapy aims at symptom removal by identifying and correcting distorted negative thinking. The other options are not directed at correcting negative thinking.
1. Which indicator of disordered communication is the nurse most likely to assess in a patient having a manic episode? a. Loose associations b. Flight of ideas c. Echolalia d. Mutism
ANS: B Flight of ideas is a continuous flow of speech marked by jumping from topic to topic. The other options are most likely to be assessed in patients with schizophrenia.
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.
11. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our hopes for our child's future are ruined. We probably won't ever have grandchildren." The nurse should use interventions to assist with the parent's demonstration of what process? a. Denial b. Mourning c. Acting out d. Manipulation
ANS: B Grief or mourning is a common reaction to having a family member diagnosed with mental illness. The grief stems from actual or potential losses such as ability to function, altered family functioning, income, and altered future prospects. Data do not support choosing any of the other options.
2. A patient reports frequent episodes of rage. The patient's problem might be associated with dysfunction of which structure? a. Parietal lobe b. Hypothalamus c. Medulla oblongata d. Reticular activating system
ANS: B Hypothalamic functions are integral to fear and rage displays, sexual arousal, and memory, by way of connections to the limbic circuit and thalamus. Research has not implicated any of the other brain structures listed in rage.
A distinctive characteristic in a patient with antisocial personality disorder is: a. feelings of guilt and remorse. b. disregarding the rights of others. c. responsiveness to antipsychotics. d. responsiveness to kind suggestions
ANS: B Individuals with antisocial personality disorders have no concern for what is right or wrong or for the rights of others. They frequently violate others' rights and frequently break laws in their "me first" thinking. These individuals exhibit no guilt or remorse, show no improvement from antipsychotics, and walk all over anyone who is not able to set firm limits.
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.
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.
A psychiatric aide asks, "Can you give me some examples of how we provide structure for patients?" The nurse should offer which suggestions? Select all that apply. a. Set limits on destructive behavior. b. Direct a patient to go to a quiet place. c. Sit with a withdrawn, isolated patient. d. Distract a patient who is hallucinating. e. Help a patient contemplate needed change.
A,B,C,D
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.
The medical record notes that a newly admitted depressed patient has delusional thoughts. Which statement by this patient is most likely? a. "I am a presidential advisor." b. "Cancer is rotting my body." c. "There are aliens chasing me." d. "I discovered a cure for cancer."
ANS: B Delusions associated with depression are congruent with the depressed mood. They often relate to somatic function or being a bad person, or they focus on faults. The other delusions are more likely to be present in an individual with schizophrenia.
16. A patient is diagnosed with a bilateral frontal cerebral hemorrhage. The nurse is aware that the patient should be assessed from which possible related condition? a. Myocardial infarction b. Increased intracranial pressure c. Renal failure d. Memory loss
ANS: B Higher level injuries, such as bilateral frontal cerebral hemorrhage, can induce coma by increasing intracranial pressure. None of the other options are associated with this type of injury.
8. A patient diagnosed with mania begins lithium therapy on October 1. What is the earliest date a nurse can expect to see clinical improvement in the patient's condition? a. October 3 b. October 8 c. October 21 d. November 1
ANS: B Lithium must be given for 7 to 10 days before clinical improvement is achieved.
5. Which intervention would be most appropriate for the nurse to implement when conducting a maintenance group? a. Helping patients identify better coping strategies b. Accepting, empathizing, and showing concern c. Asking patients to identify topics for the group d. Confronting ingrained behaviors and defenses
ANS: B Support means accepting, empathizing, and showing concern while listening and talking with patients. The nurse's focus is on responding to patients' needs. Maintenance and support groups have the purpose of reinforcing or maintaining existing strengths, rather than confronting or changing behaviors, which makes identification of better coping strategies and confronting ingrained behaviors and defenses less acceptable answers. Sessions are usually structured and goal-oriented, so patients might not be offered the opportunity to talk about any topic of their choice.
9. A nurse interviews a homeless parent with two teenage children. To best assess the family's use of resources, what question should the nurse ask? a. "Can you describe a problem your family has successfully resolved?" b. "What community agencies have you found helpful in the past?" c. "Do you feel you have adequate resources to survive?" d. "What is one thing you dislike about this family?"
ANS: B The correct option asks about resource use in an open, direct fashion. It will give information about choices that the family has made to use other family members or resources in the community. The other questions do not address prior use of resources.
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.
Mental status examination
An evaluation of a client's present state, including the client's behavior and general appearance, mood and affect, speech, thought process and content, perceptual disturbances, impulse control, cognition, knowledge, judgment, and insight.
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.
During an assessment interview, as the client is talking about his past history of childhood abuse, his mind goes blank and he stops talking. This is an example of A. thought blocking B. resistance C. denial D. confabulation
During an assessment interview, as the client is talking about his past history of childhood abuse, his mind goes blank and he stops talking. This is an example of A. thought blocking
Impulse control
The ability to delay, modulate, or inhibit the expression of behaviors and feelings.
Empathy
The ability to mentally put oneself in someone else's place, viewing a person's world from his or her internal frame of reference, with the goal of gaining understanding of how he or she feels in a certain situation. This involves the nurse's sensitivity to the client's current feelings and the ability to communicate this to the client in a language that can be understood. This technique is most useful in establishing trust and expresses understanding and concern.
Therapeutic contract
The agreement between the nurse and client to work on mutually identified problems; may be written or oral in nature.
Judgment
The capacity to identify possible courses of action, anticipate their consequences, and choose the appropriate behavior.
Insight
The extent of the client's awareness of illness and maladaptive behaviors.
Affect
The external, visible expression of emotion or mood state.
Mood
The internal feeling of emotion; a person's pervasive, subjective emotional state.
Chief complaint
The reason for current contact with the mental health system, in the client's own words.
When the nurse formulates nursing diagnoses, it is necessary to be specific in describing dysfunctional behaviors so as to: a. select appropriate desirable behaviors for outcome criteria. b. analyze how the patient was feeling at the time of assessment. c. explore the context that precipitated the exacerbation of the illness. d. determine how the illness relates to the patient's total life experience.
a. select appropriate desirable behaviors for outcome criteria.
patient would most likely buy in and do well in therapy when
are actively involved in own care and are person-driven
about half of all mental disorders begin
at mid-teens
most prevalent of specific mental illness
major depression
where individuals outside of institutions may be living
nursing homes, prisons/jails, state hospitals, homeless, home with families (group or board-and-care homes, or on own)
transferrence
patient to
Physical assessment
A medical work-up (including physical examination, clinical laboratory tests, and specialized diagnostic procedures) used in psychiatry to determine if medical illness is contributing to psychiatric symptoms.
16. What is the predominant religious tradition in the United States? a. Christian b. Buddhist c. Muslim d. Jewish
ANS: A Christians compose 70% of Americans.
Differential diagnosis
The process of differentiating one disorder from another that presents similarly
Which axis of axes of the DSM-IV-TR contains the entire classification of over 300 mental disorders? A. Axis I B. Axis II C. Axis I and axis II D. Axis III
Which axis of axes of the DSM-IV-TR contains the entire classification of over 300 mental disorders? C. Axis I and axis II
realistic outcome for a patient with situational low self-esteem who will have a short inpatient stay would be for the patient to: a. write a list of strengths, abilities, and talents. b. role-play with others to improve social skills. c. replace a negative self-image with a positive one. d. respond with positive self-esteem in all encounters.
a. write a list of strengths, abilities, and talents.
deinstitutionalization
depopulating of state mental hospitals
Which mental health model has stated principles that include the belief that individuals work to improve their own health and wellness? 1. Recovery 2. Psychoanalytic 3. Developmental 4. Interpersonal
1 The first principle of the recovery model is that it is person-driven. The psychoanalytic model is focused on a more relationship-oriented self psychology and on object relations theory. The essence of self psychology is that every human being longs to be appreciated. The developmental model states that the drive of humans to live and grow is opposed by a drive to return to more comfortable earlier states and behaviors. Interpersonal disputes and role transitions often occur in family, social, or work settings; there may be differing outlooks and expectations.
When a nurse assesses a patient's nutritional history, which question demonstrates cultural sensitivity? 1 "How much do you weigh?" 2 "What foods do you eat when you are ill?" 3 "Are you the cook in your home?" 4 "Are you hungry?"
2 Assessment of intake and type or preference of food when ill respects and honors the patient's cultural diversity. Weight is not an objective indicator of nutritional staus and is not related to culture. The questions regarding who cooks and if the patient is hungry are both closed-ended questions that do not speak to cultural assessments. DIF: Cognitive level: Applying REF: p. 54 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
A patient newly diagnosed with depression tearfully expresses a need to know more about the disorder. The nurse's response to the patient's needs is based on which statement? 1 "The details regarding depression can be difficult to comprehend, especially when one is experiencing the disorder." 2 "It is known that depression is a result of the imbalance of the neurotransmitters norepinephrine and serotonin." 3 "The patient's ability to comprehend the details regarding depression is limited until the tearfulness is managed." 4 "Depression is different for each individual who experiences it, and so discussing it with patients is difficult."
2 Discussing the fact that the disorder is a result of an imbalance of neurotransmitters constitutes responsive communication that uses layperson terms. It is not responsible communication to postpone a discussion based on the belief that the subject is too difficult for the patient to comprehend. While it is true that education is unique for each patient and that emotions can interfere with the discussion, the discussion should not be postponed. DIF: Cognitive level: Applying REF: p. 46 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
The nurse demonstrates an understanding of the impact of physical considerations on a patient's ability to communicate effectively when: 1 asking a crying patient if he or she is sad. 2 assessing a patient's pain level. 3 monitoring an angry patient for an increase in pacing. 4 recognizing the importance of a patient's body language.
2 Patients with certain physical problems might experience communication difficulties. Acute physical pain often interferes with patients' abilities to think clearly and concentrate. Characteristics associated with body language such as crying and angry pacing are considered kinetic in nature. DIF: Cognitive level: Applying REF: p. 78 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
Under what circumstances may a nurse take action to prevent a mentally ill patient from leaving the hospital where he or she has been receiving treatment? 1 The patient is diagnosed with a chronic mental illness. 2 The treatment goals for the patient have not yet been achieved. 3 The interdisciplinary team agrees that the patient still needs treatment. 4 The patient was committed by the court for evaluation or mental health treatment.
4 A patient committed by a court proceeding can be prevented from leaving a facility, and doing so is legal and thus cannot be considered false imprisonment. A patient cannot be forced to remain in a hospital for treatment based solely on diagnosis, achievement of goals, or the need for treatment. DIF: Cognitive level: Applying REF: p. 24 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
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.
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 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.
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.
History of present illness (HPI)
A chronologic account of the events leading up to the current contact with the mental health professional, including a description of the precipitants, onset, duration, exacerbating and ameliorating factors, and change of symptoms over time.
Psychiatric nursing interview
A discussion between the nurse and client that is guided by the nurse with the intent of gathering the information necessary to understand and treat the client.
A euthymic mood is A. an abnormal mood B. another word for euphoria C. a normal mood D. part of the bipolar disease process
A euthymic mood is C. a normal mood
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.
Which assessment finding warrants the nurse's priority attention when caring for a patient prescribed a selective serotonin reuptake inhibitor (SSRI)? (Select all that apply.) a. Hyperthermia b. Frontal headache c. Confusion d. Photophobia e. Agitation
A, C, E The correct response suggests serotonin syndrome, an acute medical problem requiring immediate medical and nursing attention. The distracters are examples of anticholinergic effects and are not considered emergencies.
A nurse plans to teach a group of patients the basics of the change process. How should the elements be sequenced for the presentation? a. Assess the success of new behaviors. b. Observe to gain awareness. c. Draw conclusions about the problem. d. Test new behaviors. e. Determine that change is necessary.
ALL
9. A patient diagnosed with bipolar disorder is laughing and giddy one minute and seconds later is angry and sarcastic. How should the nurse document the patient's mood? a. Incongruent b. Inappropriate c. Blunted d. Labile
ANS D Lability refers to rapid mood shifts, often seemingly without provocation. This is the only term that fits the description given in the scenario.
When caring for a patient diagnosed with dependent personality disorder, the nurse should positively reinforce which behavior? a. Choosing which clothing to wear b. Asking another patient for advice c. Sitting next to the nurse at a community meeting d. Concealing anger with a family member
ANS: A Dependent patients find it difficult to make even simple decisions. They often ask advice; thus, independently choosing their own attire is a behavior to be reinforced. The other options are behaviors that reflect dependent needs and are not desirable.
After breakfast, a depressed patient pleads with the nurse, "Please let me go to my room to lie down for a while." The nurse should: a. explain that the patient must attend scheduled activities. b. bargain with the patient to attend the next activity, then rest. c. rearrange the patient's schedule to accommodate the request. d. explain that the team will be displeased if the schedule is not followed.
ANS: A Depressed patients often want to lie down, whether or not they wish to sleep. Solitude permits self-defeating ruminations and should not be encouraged. Kind firmness in helping the patient adhere to the treatment program is necessary. Because the patient has only been up long enough to eat breakfast, rest should not be necessary. Bargaining is not therapeutic. Threatening the team's displeasure is not therapeutic as a motivator.
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.
22. A 15-year-old patient is seen for evaluation by court order. The parents seek to have this teen declared incorrigible because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize that these behaviors often occur in adolescents who have what experience? a. Childhood sexual abuse b. Antisocial personality disorder c. Early onset schizophrenia d. Ritual physical abused
ANS: A Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in teens who are sexually abused. These behaviors are not as closely aligned with any of the other options.
9. Contemporary cultural rejection of certain sexual behaviors is determined primarily based on what characteristic of the sexual act? a. Involving coercion rather than consent b. Associated with homosexual contacts c. Using artificial devices d. Resulting in orgasm
ANS: A Sexual acts that are forced on another are considered both morally and legally unacceptable. The other options are used less often as evaluation criteria.
5. A nurse assesses soldiers in a combat zone. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)? a) After exposure to a blast b) Before departing to return home. c) One year after returning from combat d) Immediately upon return to the United States
ANS: A TBI manifests shortly after the injury and usually resolves in days or weeks. It would be most important to screen after exposure to an explosion and before returning to the United States. PTSD can have a very long lag time; in some instances, it can be 20 years or more.
A psychiatric technician says, "I get annoyed with patients who self-mutilate over things other people would ignore. I think they just do it to get attention." Select the nurse's best response. a. "Many people feel the way you do. If you are unable to come to terms with the issue, we can transfer you." b. "Self-mutilation is a serious problem. Patients with this personality disorder may complete suicide." c. "We have to consider each case individually. Some are manipulative, and others are serious." d. "You seem to be having difficulty empathizing and remaining nonjudgmental."
ANS: B Every patient is entitled to respectful care. The nurse must respond by teaching the psychiatric technician that what he considers a minor problem is actually a major mental health problem. The nurse should identify the risk for completed suicide. The other options do not capitalize on this teaching opportunity.
14. The nurse who uses the interpersonal model as a basis for practice will focus assessment on identifying which patient issue? a. Intrapsychic conflicts b. Relationship problems c. How the environment affects behavior d. The patient's achievement of development tasks
ANS: B Interpersonal therapists assess for current difficulties in the patient's relationships with others. Learning new, more effective interpersonal skills becomes a goal of therapy. Psychoanalytic therapists focus on intrapsychic conflicts. The other options are not the focus of the model.
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.
1. When considering the definition of pedophila, which individuals are at highest risk of being sexually victimized by a 25-year-old pedophile? (Select all that apply.) a. Male, age 15 b. Male, age 12 c. Female, age 13 d. Female, age 8 e. Either gender, age 5
ANS: B, D, E By definition, the victim of pedophilia must be younger than 13 years old, and the pedophile must be 16 years old or older and at least 5 years older than the victim. Pedophilic behavior can be expressed for opposite-sex children, same-sex children, or both.
7. Which personality characteristic would the nurse expect in a patient diagnosed with an eating disorder? a. Grandiosity b. Impulsivity c. Perfectionism d. Suspiciousness
ANS: C Often, the individual with an eating disorder is seen as compliant, perfectionist, introverted, and having self-esteem and relationship problems. The other characteristics are rarely seen among patients with eating disorders.
5. A patient who has taken lithium for 6 months reports, "I go to the bathroom many times a day and pass large amounts of very pale urine." The nurse's action should be based on the understanding that these symptoms may indicate which problem? a. Atactic toxicity b. Uremic syndrome c. Diabetes insipidus d. Interstitial nephritis
ANS: C Symptoms of diabetes insipidus include voiding large amounts of dilute urine many times a day. Nephrogenic diabetes insipidus is caused by the inhibition of the cyclic adenosine monophosphate (cAMP)-dependent action of the antidiuretic hormone on the distal-tubule collecting duct cells. This problem is sometimes associated with lithium therapy. The symptoms detailed are not consistent with any of the other options.
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.
10. The hippocampus of a patient diagnosed with Alzheimer disease will likely be affected by what related process? a. Narrowing of the subarachnoid space b. Overproduction of cerebrospinal fluid c. Blockage of cerebrospinal fluid outflow d. Brain atrophy associated with cellular degeneration
ANS: D In Alzheimer disease, when brain cells degenerate, the brain atrophies and the ventricles enlarge to fill the existing space. None of the other options are related to this situation.
3. The nurse interviews a patient who restricts food and is 25% underweight. When the patient says, "I still need to lose weight. I'm not thin enough" which defense mechanism is being implemented? a. Rationalization b. Projection c. Splitting d. Denial
ANS: D When the individual with anorexia nervosa insists that being 25% underweight is not a problem (and thinking that she is too fat, when in fact she is emaciated), the defense mechanism responsible is denial. Rationalization involves making excuses, projection involves blaming others, and splitting involves the inability to integrate good and bad in one concept.
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.
Collateral history is obtained A. from the client through open-ended questions B. only with the client's consent in emergencies C. family, friends, and healthcare providers D. solely from experts in the field
Collateral history is obtained C. family, friends, and healthcare providers
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.
12. A nurse assesses a 3-year-old child diagnosed with autism spectrum disorder (ASD). Which finding is most associated with the child's disorder? a. Cries when frustrated. b. Inability to identify colors. c. Shows no interest in playing with other children. d. Anxiety when separated from a parent.
NS: C Autistic disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers nearly always mention the child's failure to develop interpersonal skills. The distracters are expected behaviors for a 3-year-old child.
The psychiatric nurse must consider the client's culture without A. asking too many questions B. involving the family C. using an interpreter D. stereotyping the client
The psychiatric nurse must consider the client's culture without D. stereotyping the client
Homicidal thoughts
Thoughts to kill or harm others.
When is nurse self-disclosure appropriate in a therapeutic relationship? A. To help the nurse cope with her own relationship problems B. To transition from a therapeutic to a social relationship with a client C. To improve the therapeutic alliance with the client D. To allow the client an opportunity to help the nurse
When is nurse self-disclosure appropriate in a therapeutic relationship? C. To improve the therapeutic alliance with the client
During a team meeting the RN who is experiencing a countertransference reaction to a patient would state: a. "He reminds me so much of my sweet uncle." b. "That patient asked me out to dinner." c. "I think the team needs to discuss how best to manage the patient's manipulative behaviors." d. "I believe it's okay to cry."
a rationale: Countertransference usually consists of feelings related to persons other than the patient but transferred to the patient. This range of both positive and negative feelings may interfere with the ability to be therapeutic. Reporting a patient's attempt at arranging a social interaction or the need to manage a patient's maladaptive behavior are appropriate occurrences to report to the team but do not demonstrate countertransference. Crying is not associated with countertransference.
A nurse and patient agree on problems to be addressed during a brief hospital stay. Which inference is correct? a. The relationship is moving into the working stage. b. The nurse should reinforce messages about termination. c. The nurse needs to direct the patient to begin journaling. d. Management of emotions must be ensured before work can continue.
a. The relationship is moving into the working stage.
A patient tells the nurse, "I was raped a month ago. Since then I've felt anxious and have been unable to talk normally to my husband. I've had frequent thoughts about cutting my wrists." What is the priority nursing concern regarding this patient? a. The risk for self-directed violence b. The development of rape traumatic syndrome c. The damage that could result in poor self-esteem d. The demonstration of signs and symptoms of acute anxiety
a. The risk for self-directed violence
key element in facilitation of less restrictive treatment setting
psychotropic meds
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.
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.
A patient demonstrating borderline personality disorder says, "When I met him, he was perfect and gave me everything. Now I know how bad he really is. He left me alone tonight to go out with others, so I had to cut myself." Which feature is evident? a. Splitting b. Paranoia c. Grandiosity d. Submissiveness
ANS: A Splitting involves the inability to integrate the good and bad aspects of an object, so her boyfriend is seen as perfect or entirely bad, not as a person with some traits that she likes and some that she dislikes. Paranoid tendencies involve feelings of persecution. There is no indication that the patient is submissive or grandiose.
14. A combat veteran diagnosed with a mild TBI returned to college after discharge from the armed forces. The veteran began tutoring after scoring poorly in three courses. Which strategy can the tutor use to assist the veteran's academic achievement? a) Decrease extraneous stimuli to improve attention span. b) Practice deep breathing to increase the brain's oxygen supply. c) Increase caffeine intake to counteract drowsiness and fatigue. d) Play background music while studying to improve concentration.
ANS: A TBI produces multiple cognitive problems that are likely to interfere with memory and learning. Many persons with these injuries have difficulty excluding sensory stimuli, which impairs concentration and attention span. Background music would further impair concentration. Caffeine would increase stimulation but not improve cognitive processing. Deep breathing is helpful for producing relaxation for anyone, but it would not support memory and learning.
8. A nurse at a behavioral health clinic sees an unfamiliar psychiatric diagnosis on a patient's insurance form. Which resource should the nurse use to discern the criteria used to establish this diagnosis? a. The Diagnostic and Statistical Manual of Mental Disorders (DSM) b. Nursing Diagnosis Manual c. A psychiatric nursing textbook d. A behavioral health reference manual
ANS: A The DSM gives the criteria used to diagnose each mental disorder. The distracters do not contain diagnostic criteria for mental illness.
16. The parent of a 26-month-old child says, "My child refuses toilet training and shouts 'No!' when given direction. What do you think is wrong?" Select the nurse's best reply. a. "This is normal for your child's age. The child is striving for independence." b. "The child needs firmer control. Punish the child for defiance and saying 'no.'" c. "There may be developmental problems. Most children are toilet trained by age 2." d. "Some undesirable attitudes are developing. A child psychologist can help you develop a remedial plan."
ANS: A The distracters indicate that the child's behavior is abnormal when, in fact, this behavior is typical of a child around the age of 2 years whose developmental task is to develop autonomy.
4. What should the nurse consider as the initial step in the nurse-patient relationship for a patient diagnosed with anorexia nervosa? a. Formulate the nurse-patient contract. b. Place limits on the family involvement in treatment. c. Identify a therapeutic group of similar aged patients. d. Use confrontation to establish boundaries and limits.
ANS: A Trust is the foundation to the nurse's effectiveness. A contract is formulated early in therapy to give the patient the opportunity to participate in treatment. This increases the patient's sense of control. By establishing contractual behavioral limits, manipulation and power struggles can be minimized. Recommending a therapeutic group and using confrontation to attack denial are later interventions. Family members are encouraged to take part actively in the treatment of the patient.
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.
21. A patient is diagnosed with severe depression. The nurse will prepare a plan to teach the patient about medications that improve brain availability of which neurotransmitter? a. Serotonin b. Dopamine c. Acetylcholine d. Glutamate
ANS: A Two neurotransmitters believed to be in low concentration at brain synapses of patients with depression are norepinephrine and serotonin. Most antidepressants act to increase availability of one or both of these neurotransmitters. None of the other options are directly associated with the triggering of depression.
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.
1. Which assessment finding indicates a need for immediate intervention following a brain stem injury? (Select all that apply.) a. Cheyne-Stokes breathing b. Decerebrate positioning c. Loss of pupillary response to light d. Combative, aggressive behaviors e. Asymmetric response to pain stimuli
ANS: A, B, C To assess focal brain stem structural injury, patterns of respiration (Cheyne-Stokes breathing), asymmetric responses to pain or motor reflexes, loss of pupillary response to light or unilateral pupil dilation, loss of conjugate eye gaze or combined movement of both eyes in the direction when the head is moved or when cool or warm water is poured into the ear, and patterns of limb posturing (decerebrate = both arms and legs extended, decorticate = arms flexed, legs extended) can indicate this important and emergent state for immediate intervention. Aggression is not associated with this type of injury.
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.
3. A combat veteran diagnosed with moderate traumatic brain injury (TBI) will begin pharmacologic therapies that include psychotropic medication. What information should the nurse provide? Select all that apply. a) "We will monitor you closely for how each medication affects you." b) "Medications can be expected to dramatically improve your symptoms." c) "Please be patient as your health care provider identifies the best drugs for your problems." d) "The blood levels of most medications you take will need to be checked with laboratory testing." e) "Be prepared for frequent dose changes as your health care provider adjusts the dose to meet your needs."
ANS: A, C, E Patients with TBIs are frequently overly sensitive to psychotropic medications, so close monitoring is important. However, TBI can also create drug resistance. As a consequence of both dynamics, medication adjustments are frequent and frustrating for the patient. Very few of the medications need serum monitoring; it would be misleading to say "most" do. It's important not to make promises related to how effective the drugs may or may not be.
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.
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.
2. A woman who has been repeatedly abused by her partner comes to the emergency department with severe contusions. She tells the nurse, "I was almost killed me this time. I need to do something." What is the nurse's priority intervention? a. Document the woman's injuries. b. Help the patient devise a safety or escape plan. c. Encourage the patient to take independent action. d. Provide referrals contingent on the patient leaving the abuser.
ANS: B Individuals who are victims of partner abuse should have an escape plan. This is of high priority when the victim's life is endangered. Encouraging the victim to take independent action is of less help than offering concrete assistance such as providing referrals and giving emergency phone numbers. Referrals should never be contingent on leaving, which might be possible only after the victim has made use of the referral and has assistance in place. Documentation is important, but not the nurse's first action.
3. Which intervention would be most therapeutic as a nurse provides initial care for a client who was abused by their partner? a. Validate the truthfulness of the victim's comments. b. Avoid pressuring the victim or disparaging the abuser. c. Acknowledge the victim's inability to change the situation. d. Allow the partner to stay with the victim during an interview.
ANS: B Nurses should never pressure a victim to leave the abuser. The patient must make the decision without coercion. Leaving is dangerous, because it escalates the violence and might result in death. Neither should the nurse disparage the perpetrator. The victim still cares about the batterer. The nurse should ask directly about abuse. The nurse should not suggest that the individual is unable to take constructive action. The patient should have a safe environment, without the abuser, to discuss the events. The nurse should not question the truthfulness of the victim's complaints.
16. Which observation during morning rounds should receive a nurse's priority attention? a. Breakfast is late being served. b. A sink is leaking, leaving water on the bathroom floor. c. The daily schedule has not been posted on the unit bulletin board. d. A small group of patients is complaining that one patient turned down the TV volume.
ANS: B Safety is the component of therapeutic milieu management that takes priority over the other components. A patient could be injured if he or she slipped and fell. The other problems do not pose a threat to patient safety.
17. An adolescent in a residential program threatens to throw a pool ball at another adolescent. Which comment by the nurse would effectively set limits? a. "You will be taken to seclusion if you throw that ball." b. "Do not throw the ball. Put it back on the pool table." c. "Attention everyone: We're all going to the gym." d. "Please do not lose control of your behavior."
ANS: B Setting limits uses clear, sharp statements about which behavior is not allowed and guidance for performing a behavior that is expected. The distracters represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the child's developing self-control that may be ineffective.
6. When assessing older adults, the nurse should pay particular attention to which demographic group with the highest suicide risk? a. Hispanic men b. Caucasian men c. Caucasian women d. African-American women
ANS: B The suicide rate for Caucasian male older adults is higher than for any of the groups listed in the other options. Although women make more suicide attempts, men have a higher suicide attempt-to-completion ratio than women.
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.
6. The greatest impact in the care of the mentally ill over the past 50 years is represented in which nursing statement to a newly admitted patient? a. "You will benefit from attending the assigned self-help groups" b. "Outpatient therapy will be prescribed as a part of your post discharge therapy." c. "Let's talk about the psychotropic drugs you've been prescribed." d. "This is a written copy of your patients' rights."
ANS: C The advent of psychotropic drugs allowed patients to normalize thinking and feeling. As psychosis diminished, the individual became accessible for psychotherapeutic interventions. Hospital stays were shortened. Hospital milieus improved. Though important, none of the other choices has had such a significant impact.
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.
13. When working with clients who have experienced rape, what should immediate care focus upon? a. Collecting evidence for legal purposes b. Notifying law enforcement to initiate a search for the rapist c. Helping the client feel both physically and emotional safe d. Documenting the victim's comments for future reference in care planning
ANS: C The focus of care is first helping the victim feel safe. Assessment questions and the physical procedures often seem as intrusive violations of privacy, and even physically threatening to an already vulnerable individual. The remaining options are best addressed after the basic need for safety and security are met.
2. A patient diagnosed with anorexia nervosa has the nursing diagnosis imbalanced nutrition, less than body requirements, related to inadequate food intake. What is an appropriate long-term goal of the treatment plan for this patient? a. Gain 1 to 3 lb weekly. b. Exhibit fewer signs of malnutrition. c. Restore healthy eating patterns and normalize weight. d. Identify cognitive distortions about weight and shape.
ANS: C The goal directly related to the nursing diagnosis is to restore healthy eating patterns and normalize weight. The distracters are short-term or vague or are not directly related to the nursing diagnosis.
2. What are the best menu selections for lunch for a hyperactive patient during a manic episode? Select all that apply. a. Cherry pie b. Macaroni and cheese c. Chocolate chip cookies d. Tossed salad with ranch dressing e. Roast beef sandwich on whole-grain bread
ANS: C, E A hyperactive patient experiencing a manic episode is often too overactive to sit and eat, so the nurse must provide food that can be eaten out of hand while the patient walks around. A sandwich and cookies provide protein, carbohydrates, fat, and fiber.
10. Which nurse is at risk of being guilty of committing a legal tort? a. The primary nurse who does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced-practice nurse who recommends that a patient who is dangerous to self and others be involuntarily hospitalized. c. A nurse who suggests that a patient's admission status be changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse who gives a PRN dose of an antipsychotic drug to a patient to prevent violent acting out because the unit is short staffed.
ANS: D A tort is a civil wrong demonstrated by a person who violates the legal rights of another. Giving unnecessary medication for the convenience of staff controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify a tort since considering the situations described, no patient right has been violated.
19. An individual diagnosed with schizophrenia has a history of medication nonadherence. When inpatient psychiatric care is not indicated, which service is the preferred referral? a. Primary care b. Outpatient counseling c. Apartment residential living d. A group home with 24-hour supervision
ANS: D Although inpatient hospitalization is unnecessary, the individual requires an environment in which medication compliance can be fostered. In this case, the group home would provide the best alternative. The other options do not provide adequate supervision.
18. A parent says, "My son and I argue constantly since he started using drugs. When I talk to him about not using drugs, he tells me to stay out of his business." What nursing action most appropriately addresses the parent's concern? a. Educate the parent about the stages of family development. b. Report the son to law enforcement authorities. c. Refer the son for substance abuse treatment. d. Make a referral for family therapy.
ANS: D Family therapy is indicated, and the nurse should provide a referral. Reporting the child to law enforcement would undermine trust and violate confidentiality. The other distracters may occur later.
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.
11. A talkative member of a support group for patients diagnosed with bipolar disorder has monopolized the group discussion for 15 minutes. How should the nurse leading the group best intervene? a. Maintaining silence. It is important for group members to give feedback to each other b. Encouraging the patient to continue. Patients learn from each other in group sessions c. Saying, "You must allow some of the other members of the group to talk. You cannot monopolize the conversation" d. Addressing the patient by name and saying, "I'm glad you shared your thoughts with us. Let's hear what others think"
ANS: D This intervention provides support for the dominant patient but opens the floor for contributions from others. Doing nothing or encouraging the patient to continue would be ineffective strategies, because they fail to recognize the needs of others in the group.
15. A patient backs into a corner of the room and shouts at the nurse, "Stay away from me." What is the nurse's best initial nursing intervention in this situation? a. Obtain an order for seclusion. b. Administer a PRN antipsychotic drug. c. Call for assistance to physically restrain the patient. d. Talk to the patient in a calm, nonthreatening manner.
ANS: D Verbal intervention provides the least restrictive alternative in this situation. Verbal intervention might halt escalation and prevent the need for medication or the use of restraint or seclusion. Seclusion, restraint, and medication usage are all more restrictive than verbal intervention.
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.
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 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
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.
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 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.
A patient with suicidal ideation is hospitalized. What is the priority intervention? a. Negotiating a no-harm contract b. Facilitating attendance at groups c. Administering a psychotropic drug d. Determining the precipitating situation
a. Negotiating a no-harm contract
A patient is withdrawn and avoids talking to the nurse. The best initial intervention for the nurse would be to: a. offer to listen and help. b. directly ask why the patient does not wish to talk. c. involve the patient in a group activity to decrease isolation. d. respect the patient's desire not to talk and leave the patient alone.
a. offer to listen and help.
A nurse tells a patient, "I know how you feel. My spouse can be very insensitive too. I am also considering divorce." Analysis suggests that the nurse is: a. self-disclosing inappropriately. b. experiencing countertransference. c. using empathy to establish trust with the patient. d. encouraging the patient to express negative feelings.
a. self-disclosing inappropriately.
Realistic short-term goals for a patient who is newly admitted to the hospital should be achievable in: a. 1 to 2 days. b. 4 to 6 days. c. 1 to 2 weeks. d. 2 to 4 weeks.
b. 4 to 6 days
The nurse practicing with therapeutic intentions versus social ones will: a. offer to visit the patient following discharge. b. assess the patient's needs following discharge. c. ignore the patient's requests for a date while on the unit. d. feel sadness and cry in response to the patient's depression.
b, rationale: The establishment and maintenance of objectivity and goal-directedness is crucial in therapeutic relationships. Assessing patient needs in preparation for discharge demonstrates therapeutic intentions. Offering to visit the patient following discharge is an example of blurring boundaries and the risk of unprofessional conduct that may come as a result. Inappropriate social requests should not be ignored but should be discussed with the team for decision-making purposes. Crying and feeling sad in response to a patient's condition may suggest a potential for a boundary violation as an example of countertransference.
A psychotic patient tells the nurse, "Get away from me or I'll hit you. You're sucking the thoughts out of my head." To best de-escalate the situation, the nurse should: a. direct the patient to a chair. b. deny taking the patient's thoughts. c. increase the distance between nurse and patient. d. tell the patient, "You will be restrained if you hit me."
c. increase the distance between nurse and patient.
As the nurse plans care for a newly admitted patient, identification of dysfunctional behaviors will provide the focus for: a. evaluation. b. nursing diagnosis. c. nursing interventions. d. outcome identification.
c. nursing interventions.
Select the best outcome for a nurse to include in the care plan for a withdrawn patient who says, "I would like to have more friends." Within 3 days, the patient will: a. be more outgoing. b. develop greater independence. c. participate in one group activity. d. increase socialization with others.
c. participate in one group activity.
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 newly admitted patient tells the nurse, "The voices are bothering me." The nurse should first: a. ignore the patient's reference to voices. b. distract the patient from the hallucinations. c. tell the patient that the voices do not exist. d. seek a description of the voices and identify themes.
d. seek a description of the voices and identify themes.
four of the top medical disorders causing disability
major depression, schizophrenia, bipolar disorder, alcohol abuse
When a case manager uses a telephone to communicate with a high-risk patient, what aspect of illness is most positively impacted? 1 Relapse potential 2 Social isolation 3 Medication compliance 4 Suicide prevention
1 Case management for high-risk patients can utilize phone contact to facilitate discharge planning and increase adherence to follow-up appointments and treatment, thus reducing recidivism (relapse). While telephone conversations can help minimize social isolation, that is not the focus of the case manager's interventions. Medication compliance and suicide prevention would require the patient taking the initiative to call the case manager. DIF: Cognitive level: Understanding REF: p. 76 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
The nurse is caring for a severely depressed patient who, while driving, accidentally killed a child who darted out into traffic. Which nursing intervention is focused upon the patient's content communication themes? 1 Assessing for suicidal ideations 2 Encouraging a discussion regarding the guilt the patient feels 3 Exploring the role family can play in the patient's recovery 4 Identifying ways the staff can assist the patient in finding inner peace
1 Content themes go beyond the words that a patient is saying and examine underlying messages about patients' perceptions of themselves and their problems including the risk for suicide. Mood themes relate to affect and the feelings conveyed while patients discuss their issues and concerns. Feelings often reflect shame, guilt, anger, sadness, and fear, which might or might not match the content theme. Assessing for interaction themes involves examining the ways in which patients relate to family, friends, other patients, and staff. DIF: Cognitive level: Applying REF: p. 78 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
How should the nurse respond when a community leader comments: "These homeless people are really a problem. Many of them seem mentally ill."? 1 "You must consider funding mental health assessments and services for these people." 2 "The increase in available homeless shelters is needed to help meet their basic needs." 3 "Law enforcement authorities require effective intervention training when dealing with the mental ill homeless population." 4 "If the community could provide employment opportunities for the homeless it would help them become independent."
1 Effective management of the homeless population begins the assessment process and focuses on money and services needed in the community. While basic needs are important, evidence suggests that many homeless persons have unmet mental health needs. Law enforcement authorities intervene only on a crisis basis, as a last resort for the individual. Vocational training and job skills might be of benefit to this population but may not be the highest priority or responsive to current needs.
Whose views were most influental in shaping the practice of psychiatric nursing and are still referred to today? 1 Hildegarde Peplau 2 Harriet Bailey 3 Linda Richards 4 Dorothea Dix
1 Hildegarde Peplau (1952, 1959) developed a model for psychiatric nursing practice. Her book, Interpersonal Relations in Nursing (1952), influences practice to this day. In 1920, Harriet Bailey wrote the first psychiatric nursing textbook. Linda Richards, the first American psychiatric nurse, was a graduate of the New England Hospital for Women. Richards spent much of her professional career developing nursing care in psychiatric hospitals and also directed a school of psychiatric nursing in 1880 at the McLean Psychiatric Asylum in Waverly, Massachusetts. Dorothea Dix (1802 to 1887), one of the first major reformers in the United States, was instrumental in developing the concept of the asylum.
A patient in an outpatient program asks the nurse if he can keep a secret. The nurse replies: 1 "I am not able to keep a secret, because I share our work together with the health care team here." 2 "Please tell me first, and then I will decide." 3 "I will only tell your secret if it involves harm to you or another." 4 "Yes, I can keep a secret."
1 In a therapeutic relationship the nurse is not a friend but is an advocate, one who facilitates care within a team approach. The patient must know the nurse's position on secret keeping before sharing information. While safety is a major nursing concern, there are other issues that require disclosure to the team. Secret keeping is a potential professional-boundary violation. DIF: Cognitive level: Analyzing REF: p. 79 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
Who proposed that early childhood experiences that interfere with the development of trust can lead to later issues of abandonment and shame? 1 Loder 2 Levin 3 Ion 4 Grossoehme
1 James E. Loder (1989) postulated that early developmental experiences set the stage for later spiritual dynamics within the individual. By the age of 9 months the child will understand when the mother is not present and will experience anxiety at her absence. The child's burgeoning capacity to trust is strengthened by the presence (face) of the nurturer. Loder notes that the child experiences no shame when gazing at this face, so this model can be useful in helping deal with issues of abandonment and shame. Levin and Ion identified four factors of resilience essential for coping, which Levin calls the Four B's. Grossoehme made observations concerning the disparity between the professed importance of spiritual care and the actual treatment that psychiatric patients generally receive. DIF: Cognitive level: Remembering REF: p. 59 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
An Asian-American patient is presecribed a psychotropic medication. He expresses a concern by stating, "I heard that my body may react to certain medications in a different way because of my heritage." The nurse will respond to his concern by stating: 1 "There are enzymes that can affect the metabolism of some medications for individuals in your cultural group." 2 "There are differences but no significant effects." 3 "Please don't be too concerned about this. Your doctor will speak to you about it." 4 "How did you find out about this issue?"
1 Since this is a true statement, the best response is to provide accurate psychoeducation information for the individual that includes the possible effects and the measures taken to avoid them. This is a question the nurse should be prepared to answer, and it should not be passed along to the doctor; doing so appears to minimize the individual's concerns. Asking how the patient became aware of this information minimizes his concerns and serves only to distract him from an answer. DIF: Cognitive level: Applying REF: pp. 53-54 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
In meeting the spiritual needs of the patient experiencing psychosis, it is best for the nurse to speak: 1 slowly and concretely. 2 about the subject during the initial assessment. 3 quietly and abstractly. 4 very little about this subject.
1 Slow responses afford processing and facilitate understanding, as does the use of concrete words and examples. The initial assessment may not be the appropriate time to address the issue of the patient's spiritual needs. Speaking quietly may not meet the patient's needs; abstract language with the psychotic patient is not supported in evidence-based care. It is not appropriate to avoid the subject, since it does not speak to the patient's spiritual needs. DIF: Cognitive level: Applying REF: pp. 60-61 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
Parents are struggling to understand their teen's diagnosis of schizophrenia. In teaching, the nurse will state: 1 "It is believed that schizophrenia is related to a surplus of a substance in the brain called dopamine. Medications, therapies, and treatments can help manage the disorder." 2 "There is little known about what may cause schizophrenia. What is known is that the brain develops in an abnormal manner." 3 "Schizophrenia is not believed to be genetic in nature." 4 "There has been little research in the cause of schizophrenia."
1 The option that is most responsive in communicating, in layperson terms, current understanding regarding the causation of schizophrenia identifies the role of dopamine. Although a definite cause is still unconfirmed, research has produced several viable theories regarding the cause of schizophrenia. One of those theories includes a possible genetic link. DIF: Cognitive level: Understanding REF: p. 46 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity Awarded 0.0 points out of 1.0 possible poin
When it is documented that a patient has basal ganglia dysfunction, the nurse will expect which assessment findings? (Select all that apply). Sudden, unexpected flailing of an arm Correct Resting tremors in the hands Correct Involuntary, rapid eye movement Correct Decreased, unilateral tendon reflexes Incorrect General lack of coordination
1, 2, 3 Basal ganglia dysfunction can result in hemiballismus (a sudden, wild flailing of one arm), nystagmus (involuntary rapid eye movements), and resting tremor as seen in parkinsonism. A decrease in tendon reflexes unilaterally and a general lack of coordination described as ataxia are related to cerebellar dysfunctions. DIF: Cognitive level: Understanding REF: p. 43 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
What elements must be present for a nurse to be found guilty of negligence and for damages to be awarded? (Select all that apply). 1 The nurse had a duty to care for the patient. Correct 2 The nurse had an obligation to provide reasonable care. Correct 3 The nurse failed to perform an expected duty. Correct 4 The nurse was aware that the standard of care was not met. 5 The nurse's actions resulted in injury to the patient.
1, 2, 3, 5 The four elements that must be present for a plaintiff to recover damages caused by negligence are the nurse's duty to care, the obligation of reasonable care (i.e., standard of care), breach of duty, and injury proximately caused by a breach of duty. It is not necessary that the nurse be aware that the standard of care was not being met. DIF: Cognitive level: Understanding REF: p. 22 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
In addition to race and ethnicity, what other factors are significant when considering cultural diversity? (Select all that apply). 1 Age 2 Socioeconomic status 3 Religion Correct 4 Size of birth family 5 Gender
1, 2, 3, 5 The term cultural diversity might encompass areas such as age, gender, socioeconomic status, religion, race, ethnicity, mental illness, and physically challenging conditions. Neither the size nor the composition of one's family appears to have a significant impact on cultural diversity. DIF: Cognitive level: Understanding REF: p. 51 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
Which actions will best assure that the nurse is delegating to a novice, unlicensed assistive personnel (UAP) both legally and with attention to the patient's care needs? (Select all that apply). 1 Consulting the facility's policy manual to determine the UAP's scope of practice 2 Reviewing the state's nursing practice act to determine if the task is delegatable 3 Assigning the novice UAP to shadow an experienced UAP who is proficient at the task 4 Initially supervising the UAP performing the delegated task 5 Assuring the patient that the novice UAP is qualified to perform the task
1, 2, 4 When delegating, the nurse should know and follow the local hospital procedures so as to stay within his or her scope and authority, ensure that UAPs assigned have been fully trained and are qualified to carry out the tasks they are expected to perform, and know the limitations and responsibilities of nursing practice of his or her state. Such responsibility may not be delegated to another UAP. Notifying the patient is not considered a part of the delegating process. DIF: Cognitive level: Analyzing REF: p. 23 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
The psychiatric mental health nurse who demonstrates an understanding of patient rights will (Select all that apply): 1 avoid discussions of multidisciplinary team and patient concerns except in areas of privacy. Correct 2 honor the patient's medical and psychiatric advanced directives. Correct 3 remain "logged on" to the patient's electronic medical record during the shift. 4 introduce self first before initating any patient-focused discussions. Correct 5 request permission to interact and work with the patient.
1, 2, 4, 5 Considering privacy, honoring patient requests, and demonstrating courtesy and respect are all examples of patient advocacy and appropriate professional conduct. Confidentiality requires that a patient's medical record be opened only when actual documenting is occurring. DIF: Cognitive level: Applying REF: pp. 26-30 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
Which factors contribute to the formulation of health care actions and beliefs on the part of both nurses and patients? (Select all that apply). 1 One's individual definition of health 2 The amount of education one has 3 How one believes illness is caused 4 One's cultural worldview 5 Personal experience with chronic illness
1, 3, 4 Nurses' and patients' health care actions and beliefs are generally formulated by three factors: (1) their definition of health; (2) their perception of the way in which illness occurs; and (3) their cultural worldview. Education and experience with illness are not recognized as factors that contribute to the formulation of one's beliefs and actions regarding health care. DIF: Cognitive level: Understanding REF: p. 51 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
Which outcomes are associated with mental health's period of psychiatric drugs? Select all that apply. 1 Hospital stays are now shorter. 2 The cost of medications have decreased. 3 Hospital environments are now more therapeutic. 4 Medications have become a primary treatment modality. 5 Acute-care hospital stays are less expensive as a result.
1,3 Major events associated with the period of psychiatric drugs include the shortening of the length of hospital stays and the improvement of hospital environments. The introduction of mental health-oriented medications has not significantly affected costs of medications or hospital stays. While medications are a vital part of mental health treatment, they are not necessarily considered primary.
The nurse who utilizes the interpersonal approach in working with a patient will say: 1. "What are the challenges with the relationship between you and your partner?" 2. "What usually happens when you become angry?" 3. "Whom would you trust to manage your business affairs?" Incorrect 4. "You say you want to lose weight, yet you spent all your money on fast food."
1. An assessment of significant relational issues according to Sullivan would be associated with the interpersonal approach. Assessment of the patient's appraisal of the stress/coping response (Lazarus) would be associated with assessing anger. Assessment of Erikson's Developmental Theory (trust-versus-mistrust mastery) is associated with trust. A statement by the nurse about the patient's maladaptive response in spending money on fast food, pointing out irrational thoughts leading to maladaptive behaviors, would be associated with the cognitive approach.
Which neurotransmitter is most widely associated with the biologic theory for the development of schizophrenia? 1 Norepinephrine 2 Dopamine Correct 3 Serotonin 4 Acetylcholine
2 By far the most celebrated and widely known biologic theory for schizophrenia is the dopamine hypothesis. According to this theory, schizophrenia is caused by alterations of dopamine levels in the brain. This theory regarding the cause of schizophrenia is not associated with norepinephrine, serotonin, or acetylcholine. DIF: Cognitive level: Remembering REF: p. 46 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
In some patients diagnosed with schizophrenia, blood flow in the frontal lobe is diminished. The nurse would expect such a patient to experience which deficit? 1 Inability to recall a telephone number 2 Ineffective at planning a family birthday party 3 Poor boundaries when socializing with strangers 4 Difficulty balancing when riding a bike
2 Frontal lobe blood flow deficits limit critical thinking, planning, and organizing. Memory, associating social boundaries, and physical balance would not be affected by such a condition. DIF: Cognitive level: Applying REF: p. 19 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
When the nurse is employing spiritual care for a patient, it is most important to do so with: 1 one's own beliefs as a guide. 2 trust and compassion. 3 direction and control. 4 a referral only.
2 Meeting the patient's needs with both trust and compassion honors the patient while supporting the intrinsic needs of the patient with beliefs of faith. Basing care on one's own belief system may indicate countertransference and may not be congruent or supportive of the patient's beliefs. Being controlling and directive is nurse-focused care and not patient-centered care. Care should allow patient direction and control. Referrals are important but do not stand alone as the only intervention. DIF: Cognitive level: Understanding REF: p. 61 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
When a chronically depressed, suicidal patient asks the nurse to arrange for a clergy visit, the nurse makes a referral to which clergy member? 1 The patient's personal clergy 2 The multidisciplinary team's chaplain 3 A clergy with an interest in counseling the mentally ill 4 The clergy member whom the family identifies
2 Patients with spiritual concerns should be referred to a clinically trained spiritual care professional (usually a chaplain), and this person should be part of an interdisciplinary health care team. Community clergy, even those with an interest in the mentally ill, are usually not trained to address the spiritual needs of psychiatric patients. Family members can be biased in their selection of clergy. DIF: Cognitive level: Applying REF: p. 62 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
What is considered the key nursing component of any therapeutic treatment model? 1. The patient's readiness to engage in therapy 2. The development of a therapeutic patient-nurse relationship Correct 3. The extent to which the patient utilizes involuntary defense mechanisms 4. The nurse's understanding of the patient's maladaptive behaviors
2 Psychiatric nurses recognize that the key component in any therapeutic model is the patient-nurse relationship. The therapeutic alliance is often the best predictor of the outcome of any treatment approach. Patient readiness and reliance on involuntary defense mechanisms, as well as nursing knowledge, are components that determine treatment success, but none of these have as much impact on therapeutic outcomes as does an effective patient-nurse relationship.
What is believed to be the key to an ethnically diverse patient's ability to recover from physical and emotional illness? 1 The age and general health of the individual 2 The delivery of culturally competent health care 3 The degree of family support that the individual has 4 The amount of confidence the individual has in Western medicine
2 Research on the use of culturally competent mental health strategies has indicated that cultural competence is key to patients' recovery process. While age, health, family support, and confidence in medical treatment are factors, they are not the primary factor in a patient's recovery. DIF: Cognitive level: Understanding REF: p. 50 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
The nurse who embraces cultural competence in practice will state: 1 "I try to treat all my patients the same to avoid biases." 2 "I ask my patients to teach me what works best for them." 3 "I always ask patients why they believe they are ill." 4 "I think each patient reacts basically the same way to psychiatric medications."
2 Seeking the patient's involvement demonstrates a cultural awareness that facilitates the nurse's understanding of the patient's cultural need. It is not realistic to treat everyone the same given individuality, uniqueness of the human experience, and cultural variations and diversity. Avoidance of "why" questions is important when communicating with a patient, since the patient may already feel punished by illness. It has been proven by research that ethnic groups do react physically differently to medications in many instances. DIF: Cognitive level: Analyzing REF: p. 51 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
What is the potential long-term effect of childhood trauma and maltreatment? 1 Impaired cognitive function 2 Chronic depression 3 Early-onset schizophrenia 4 Dementia
2 Significant stress, trauma, maternal behavior, and maltreatment during childhood and adolescence are mental health issues, because they have the potential to permanently alter the structure and chemistry of the brain, which often leads to a life of depression and anxiety. There is currently no research to associate these events with impaired cognition, schizophrenia, or dementia. DIF: Cognitive level: Understanding REF: p. 48 TOP: Nursing process: Assessment MSC: Client Needs: Psychosocial Integrity
A patient discloses a history of chronic trauma to the student nurse. The student therapeutically responds: 1 "I think everything will be okay." 2 "This is difficult to talk about; I'm here to help." 3 "How long did that go on?" 4 "I know you will be feeling better soon!"
2 The correct response demonstrates the nurse's interest, concern, and availablity to the patient. It is nontherapeutic to provide false reassurance. Focusing on when the event occurred is act-based but not supportive of the patient in this context. DIF: Cognitive level: Applying REF: p. 82 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
The movement to deinstitutionalize mental patients was influentual in what legal change regarding the management of the mentally ill? 1 The length of hospital stays 2 Criteria for involuntary commitment 3 The cost of in-hosptal mental health treatment 4 The type of training required of mental health care providers
2 The deinstitutionalization movement brought about a change in commitment laws. Out of concern for the civil rights of mental patients, involuntary commitment of individuals to a state hospital became difficult. The state had to demonstrate that those accused were a clear danger to themselves or to others. Neither the length and cost of hospitalization nor the training required of health care providers was significantly affected by this movement.
By what means does an individual typically cope with anxiety that is overwhelming? 1. Acting out 2. Defense mechanisms 3. Psychosis 4. Transference
2 The ego usually copes with anxiety through rational means. But when anxiety is too painful, the individual copes by using defense mechanisms to protect the ego and diminish anxiety. Acting out, such as with physical aggression, and psychotic behavior may be seen as the outcome of an individual's inability to cope with anxiety, but they are not the typical coping mechanism used. Transference is the act of distorting personal perception of others by attributing to them qualities they do not possess.
When considering communication, what is the initial task for a nurse responsible for the care of a newly admitted patient? 1 Providing an introduction that includes one's name and professional role 2 Self-assessing for possible barriers to effective communication with the patient 3 Conveying respect and caring when engaging in the initial nurse-patient conversation 4 Allowing the patient to determine the focus of the initial nurse-patient communication
2 The nurse must recognize and overcome any habitual communication problems that might interfere with effective therapeutic communication. After such a self-assessment is made and the needed corrections are made, an informative introduction can be made that is followed by a respectful, caring conversation that is nurse-directed but patient-focused. DIF: Cognitive level: Analyzing REF: p. 82 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
The patient asks, "Why are there so many questions asked of me here?" The most therapeutic response by the nurse is: 1 "So we can help solve your problems here." 2 "Questions are asked to understand the concerns you have." 3 "It is important that you and I become friends." 4 "We are required to ask you questions as part of your therapy."
2 Identifying the patient's concerns is necessary to care for the patient therapeutically. This response accurately answers the patient's question and places the nurse alongside the patient in the therapeutic relationship. Problems are not solved or "fixed"; rather, the nurse is available to assist with healing and support the patient's independence and autonomy in planning and problem solving. Being friends is social rather than therapeutic in nature and is a possible professional-boundary violation.Therapeutic relationships are a purposeful choice rather than being forced or required. DIF: Cognitive level: Analyzing REF: p. 78 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
How can a nurse best provide patient-focused spiriual care? (Select all that apply). 1 Ask the patient to be allowed to pray with him or her. 2 Take a spiritual history as part of the assessment interview. 3 Support the patient's spiritual beliefs. 4 Always address the patient with kindness and respect. 5 Be ready to respond to a patient's request for a pastoral care referral.
2, 3, 4, 5 Nurses should do five things regarding spiritual care: (1) Take a spiritual history; (2) support and show respect for the patient's beliefs; (3) pray with the patient if the nurse is comfortable doing so and if the patient wants and requests it; (4) provide spiritual care by being kind, gentle, sensitive, and compassionate; and (5) refer to pastoral care if desired by the patient. DIF: Cognitive level: Applying REF: p. 61 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
Dementias, especially Alzheimer's disease (AD), are associated with which characteristics? (Select all that apply). 1 A deficiency of norepinephrine 2 A buildup of neurofibrillary tangles Correct 3 Microscopic changes in the cortical neurons Correct 4 A surplus of dopamine Incorrect 5 A deficiency of acetylcholine
2, 3, 5 Dementias, specifically AD, are related to brain atrophy and are characterized by microscopic changes in the cortical neurons and a buildup of neurofibrillary tangles and amyloid plaques. A deficiency in the neurotransmitter acetylcholine also occurs. The neurotransmitter theory of depression states that depression is related to decreased levels of norepinephrine, serotonin, or both. The dopamine hypothesis postulates that schizophrenia results from alterations of levels of brain dopamine. DIF: Cognitive level: Understanding REF: pp. 38-39 TOP: Nursing process: Assessment MSC:Client needs: Psychosocial Integrity
The nurse who utilizes the developmental approach in working with a patient will say: 1. "What are the challenges with the relationship between you and your partner?" 2. "What usually happens when you become angry?" 3. "Whom would you trust to manage your business affairs?" 4. "You say you want to lose weight, yet you spent all your money on fast food."
3 Assessment of Erikson's Developmental Theory is associated with trust-versus-mistrust mastery. Interpersonal Theory (Sullivan) focuses on relational issues for the patient. Assessment of the patient's appraisal of the stress/coping response (Lazarus) would be associated with assessing anger. A statement by the nurse about the patient's maladaptive response in spending money on fast food, pointing out irrational thoughts leading to maladaptive behaviors, would be associated with the cognitive approach.
Which difference between male and female brains is possibly associated with the increased incidence of depression in females? 1 Men have larger parietal lobes. 2 Women have larger frontal lobes. 3 Men produce more serotonin. 4 Women have larger limbic areas.
3 Levels of the neurotransmitter serotonin, a major chemical involved in setting moods, is 52% higher in men than in women, —possibly accounting for the higher incidence of depression in women. While it is true that men have some larger areas in the parietal lobes, whereas women have some larger areas in the frontal lobes and limbic areas, these differences are not known to be associated with the incidence of depression. DIF: Cognitive level: Understanding REF: p. 48 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
When teaching colleagues the concept of community-based care,which statement will the nurse make? 1 "The greatest challenge is to work with those identifed as the worried well." 2"Homelessness is the root of all mental illness." 3"A seamless continuity of care for the mentally ill individual is a favorable goal." Correct 4 "When treating the chronically mentally ill it is best to wait for a crisis to occur before intervening with treatment."
3 Providing care for those seeking services for mental illness should serve to support independence and autonomy and be delivered with the least amount of restriction. This is the goal of community mental health care. Working with the worried well is less intense and may actually preoccupy mental health care providers and keep them from working with the severely mentally ill. Though many homeless individuals may suffer from mental illness, homelessness does not cause mental illness. Mental health promotion and disease prevention is most respectful, least stressful, and more cost-effective.
A novice nurse shares that he is uncomfortable speaking with patients about religion and spirituality. The nurse manager responds: 1 "It's okay to avoid bringing up this issue with chronically mentally ill patients." 2 "If a patient brings it up, then listen, but you need not initiate the conversation." 3 " A simple strategy is to ask them about their faith community." 4 "Let's discuss why you're uncomfortable discussing religion and spirituality."
3 Providing the novice nurse with a simple, relevant, and respectful assessment question to initiate the conversation is the most effective response. It is not okay to avoid the issue; patients have spiritual needs and deserve support in this area of care. It is professionally appropriate to initiate a conversation with a patient, unless it is nontherapeutic for a particular patient and his or her current thought processes. "Why" serves to place the staff member on the defensive; this is an important question deserving of a educated, professional response. DIF: Cognitive level: Applying REF: p. 57 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
Which statement accurately states the basis of the M'Naghten rule regarding its impact on the mentally ill? 1 All mental ill individuals are assured the right to treatment. 2 Nonviolent mentally ill individuals have the right to refuse treatment. 3 A legally insane individual cannot be held legally accountable for a murder he or she has committed. 4 Any threat of violence toward another made by a mentally ill individual to a health care professional must be reported.
3 The M'Naghten rule states that individuals who do not understand the nature and implications of murderous actions because of insanity cannot be held legally accountable for murder. Wyatt v. Stickney, 344 F Supp 373 (MD Ala 1972), confirmed a right to treatment. Rogers v. Okin, 478 F Supp (D Mass 1979), determined the right to refuse treatment. In this case, the ruling prohibited Boston State Hospital from forcing nonviolent patients to take medications against their will. Tarasoff v. The Regents of the University of California (1976) 17 Cal 3rd 425, ruled that mental health professionals have a duty to warn of threats of harm to others. DIF: Cognitive level: Understanding REF: p. 21 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
What characteristic of schizophrenia poses a negative effect on the patient's spiritual perspective? 1 Hallucinations 2 Delusions 3 Concrete thinking 4 Paranoia
3 The incapacity to symbolize—that is, the patient's concrete thinking—can cause special problems, because it is believed thatreligious language is symbolic by its nature. While hallucinations, delusions, and paranoia present the patient with severe problems, they are not as influential as concrete thinking on the spiritual life. DIF: Cognitive level: Understanding REF: pp. 60-61 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
What is considered to be the most common barrier to the delivery of culturally competent nursing care? 1 Ethnic prejudices 2 Religion biases 3 Miscommunication 4 Racial discrimination
3 The most common barrier to the delivery of culturally competent nursing care involves miscommunication between nurses and patients. While prejudices, biases, and discrimination occur, they are not the most common barrier to the delivery of culturally competent nursing care. DIF: Cognitive level: Remembering REF: p. 51 TOP: Nursing process: Assessment MSC:Client needs: Psychosocial Integrity
What is the initial purpose for the nurse determining a patient's communication themes? 1 Initiation of discharge planning 2 Formulating long-term patient goals 3 Identifying appropriate nursing diagnoses 4 Selecting fitting nursing interventions
3 Themes are frequently the source of nursing diagnoses on which care plans are based. After the nursing diagnoses are identified, goals, interventions, and discharge planning can be initiated. DIF: Cognitive level: Analyzing REF: p. 78 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
Considering the psychoanalytic therapy model, which intervention is a major nursing therapeutic responsibility? 1. Using free association to bring repressed thoughts to consciousness 2. Interpreting the patient's dreams 3. Helping the patient identify maladaptive behaviors 4. Assessing the patient for mastery of developmental tasks
3 To support the psychoanalytic therapy model, the nurse must recognize and understand the maladaptive defense mechanisms that patients use. The nurse carefully shares observations regarding these mechanisms and works with patients to increase awareness about these behaviors to increase adaptive behaviors. It is the therapist's role to use free association (allowing the patient to say everything that comes to mind) so that repressed material can be identified and interpreted for patients. Dream analysis by the therapist helps patients uncover the meaning of their dreams, which also increases awareness about present behavior. In the developmental therapy model, the nurse conducts an assessment of the patient's level of functioning through the interpretation of verbal and nonverbal behaviors and identifies the degree of mastery of each stage up to the patient's chronologic age.
The psychiatrist Viktor Frankl is known for which observation regarding spirituality? 1 People demonstrate characteristics of either healthy spirituality or sick religiosity. 2 Spirituality is the sum total of intellectual and cultural possession. 3 While we cannot always choose our circumstances, we can choose our attitudes about our experiences. 4 Spirtuality gives life, depth, and meaning to existence.
3 Viktor Frankl was a notable psychiatrist who experienced intense suffering as a prisoner in Nazi concentration camps during World War II. He recognized that, although individuals cannot always choose their circumstances, they always have a choice about their attitudes toward their experiences. Xavier (2008), a clinical psychiatrist, offers a useful distinction from his psychiatric experience between "healthy spirituality" and "sick religiosity." Jung described spirituality as "the sum total of intellectual and cultural possessions. . . ." It was also Jung who proposed that spirit refers to something not strictly physical, which gives life, depth, and meaning to existence. DIF: Cognitive level: Understanding REF: p. 59 TOP: Nursing process: Assessment MSC: Client needs: Psychosocial Integrity
A patient confides to the nurse the intent to harm a family member. What is the nurse's initial action when complying with the Tarasoff ruling? (Select all that apply). The local police are notified of the plan. Incorrect The nurse makes an attempt to talk the patient out of the plan. The patient's clinical team discusses the seriousness of the patient's plan. The patient's psychiatrist is notified of the patient's desire to hurt the family member.
3, 4 Initially, whenever possible, a decision to communicate confidential patient communications should be discussed with the clinical team, including the patient's psychiatrist, before taking action to ensure that patients' rights are balanced with those of third parties. It may become appropriate to notify the police, but that is not the initial action. Attempting to talk the patient out of such actions would not be considered appropriate. DIF: Cognitive level: Applying REF: pp. 23-24 TOP: Nursing process: Planning MSC: Client needs: Psychosocial Integrity
In implementation of the principle of "duty to warn of threatened suicide or harm," the nurse will initially: 1 seek guidance regarding confidential client information from the agency's attorney. 2 direct all questions to the psychiatrist in charge of the patient. 3 always notify third parties whenever there is a concern of harm from the patient. 4 notify the multidisciplinary team regarding communication of client information.
4 Involve the team in discussion and decision making regarding threats; avoid working in isolation. May need to consider consulting with the agency's attorney as well in some situations. The team will need first discussion and problem solving prior to contacting the agency's attorney for guidance. The team needs discussion of the issue, along with the psychiatrist working with the patient. "Always" would be inappropriate whenever there is a concern of harm. DIF: Cognitive level: Applying REF: pp. 23-24 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
A new patient is assigned to the nurse, who begins communication. The nurse's initial statement is: 1 "Welcome to our unit. My name is David, and I will be your RN today. Do you have any questions? I will not discuss what we talk about with anyone else." 2 "My name is Ann, and I will be your nurse this evening. Where would you like to start?" 3 "Hello! What is your name? My name is Bruce, and we will work together on your discharge goals. You may tell me anything you would like, because everything you tell me will not be repeated." 4 "My name is Sally, and I will be the RN working with you today. I will be sharing our discussion with the care team here only. By what name may I address you?"
4 This statement respectfully addresses all initial concerns: introduction of nurse with name and role, the purpose of the communication, and clarification of confidentiality limits. Closed-ended questions such as "Do you have any questions?" and the sharing of incorrect parameters of confidentiality must be avoided. Initially, the nurse determines the focus of communication. DIF: Cognitive level: Analyzing REF: p. 79 TOP: Nursing process: Assessment
What is the most important component to be communicated when reporting to the incoming nursing staff regarding a patient who is admitted for emergency care? 1 The details of the reason the patient was brought to the facility 2 The name of the patient's significant others or advocate 3 Whether or not the patient has been adherent with medication 4 The beginning time and date of the emergency detention
4 Time is important in assessment, adhering to legal parameters and patient's rights, and preparing the patient for the upcoming options for care. The remaining information has importance but is not considered the most important among these options. DIF: Cognitive level: Analyzing REF: p. 25 TOP: Nursing process: Implementation MSC: Client needs: Psychosocial Integrity
A major nursing goal associated with interpersonal relationship therapy is to assist the patient in: 1. focusing attention on past experiences that distort relationships. 2. challenging any existing negative self-image. 3. developing effective problem-solving skills. 4. converting anxiety to constructive action.
4. Considering interpersonal relationship therapy, a major goal of nursing constitutes helping patients reduce their anxiety and convert it to constructive action. It is the therapist's role to focus on the patient's interpersonal issues and distortions created by past experiences. In challenging a negative self-image, the therapist presents an appraisal of the patient as a worthwhile, respectable individual with rights, dignity, and valuable abilities. Nurses help patients change irrational beliefs and reduce stress and anxiety through effective problem solving when engaging in cognitive therapy
The nurse who utilizes the cognitive approach in working with a patient will say: 1. "What are the challenges with the relationship between you and your partner?" 2. "What usually happens when you become angry?" 3. "Whom would you trust to manage your business affairs?" 4. "You say you want to lose weight, yet you spent all your money on fast food."
4. Statement by the nurse of patient's maladaptive response, pointing out irrational thoughts leading to maladaptive behaviors, would be associated with the cognitive approach. An assessment of significant relational issues according to Sullivan would be associated with the interpersonal approach. Assessment of the patient's appraisal of the stress/coping response (Lazarus) would be associated with assessing anger. Assessment of Erikson's Developmental Theory (trust-versus-mistrust mastery) is associated with trust.
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.
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 75-year-old patient with a long history of depression begins amitriptyline 100 mg/day. The patient also takes a diuretic daily for hypertension. What is the highest priority nursing diagnosis this patient is at risk for? a. Falls related to dizziness and orthostatic hypotension. b. Ineffective thermoregulation related to anhidrosis. c. Infection related to suppressed white blood cell count. d. Constipation related to slowed gastrointestinal peristalsis.
A Amitriptyline is a tricyclic antidepressants (TCA) that has a high risk of producing orthostatic hypotension. The patient is placed at even greater risk because of older age and diuretic therapy, which reduces fluid volume. The other options are either unassociated or are remote possibilities.
What is the nurse's priority assessment for a patient taking an antidepressant medication? a. Presence of suicidal ideations b. Presence of antiadrenergic side effects c. Presence of anticholinergic side effects d. Presence of symptoms of sexual dysfunction
A Antidepressant medication tends to energize depressed patients, possibly giving them the impetus to act on suicidal ideation that has been present related to the depression. This complication is particularly applicable to adolescents. Some suggest that suicidal ideation might be the actual result of antidepressant therapy. In either case the implication for nursing is clear—patients should be carefully assessed for the presence of suicidal ideation, suicidal plans, and means for carrying out the plans. This option is related to patient safety and takes priority over the other options.
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.
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.
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.
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.
What is the nurse's highest priority when caring for a patient after a tricyclic antidepressant (TCA) overdose? a. Frequently monitor blood pressure and heart rate/rhythm. b. Monitor for skin rashes, particularly on the torso. c. Measure and record intake and output every 12 hours. d. Institute cooling blankets for hyperthermia.
A It is necessary to assess cardiovascular function, because cardiovascular reactions can occur suddenly, even several days after the TCA overdose, and can result in acute heart failure. The other options are not as closely aligned with cardiovascular problems.
When teaching about the monoamine oxidase inhibitor (MAOI) tranylcypromine, the nurse should consider it a priority to provide what information? a. A list of tyramine-rich foods b. A warning to avoid direct sunlight c. Instructions to manage fever with acetaminophen d. Directions to report dry mouth and blurred vision
A MAOIs and ingested tyramine interact to produce hypertensive crisis, a life-threatening medical emergency, so it is necessary to teach the patient foods to avoid. The other options are unrelated to tranylcypromine therapy.
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.
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.
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.
Why do patients taking tricyclic antidepressants (TCAs) exhibit more side effects than patients taking selective serotonin reuptake inhibitors (SSRIs)? a. TCAs inhibit reuptake of norepinephrine and serotonin. b. TCAs selectively inhibit dopamine reuptake. c. TCAs selectively block serotonin uptake. d. TCAs block enzymatic breakdown.
A TCAs inhibit the reuptake of both norepinephrine and serotonin and because of their nonselectivity produce many side effects. The other options are incorrect statements about the action of TCAs.
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.
Resistance
A client's defense against the anxiety associated with acknowledging personal troubles and an unwillingness or ambivalence to change.
Biopsychosocial history
A comprehensive assessment of the client's lifetime biologic, psychologic, and social functioning.
Holistic psychiatric assessment
A comprehensive assessment of the client's physical, psychologic, cognitive, social, and spiritual dimensions.
Concrete thought process
A thought process in which one is able to understand only the literal meaning of words, as opposed to abstract thought process.
Evaluation of a patient's response after 1 week of tricyclic antidepressant (TCA) therapy would be expected to focus on what assessment question? (Select all that apply.) a. "Have you noticed a change in your sleep patterns?" b. "Has your appetite improved?" c. "Are you still having suicidal ideations?" d. "Are you feeling less depressed?" e. "Would you say you are less anxious now?"
A, B, E Improved appetite is likely due to the antihistaminic effect of the drug. Anxiety reduction is another positive effect of TCAs. Sedation is a therapeutic effect of some of these drugs as well. Neither improvement in mood nor elimination of suicidal ideations are likely to occur for 2 to 4 weeks.
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.
5. A patient experiencing severe panic attacks uses denial, repression, and displacement. Which nursing statement reflects an appropriate intervention regarding this patient's needs? a. "We are going to focus on exposing you to more effective coping strategies." b. "You will benefit from setting limits on use of the defense mechanisms." c. "We will discuss the benefit of changing values and beliefs." d. "Let's discuss helping you uncover the unconscious conflicts causing you trouble."
ANS: A A desired outcome would be that the patient will use more effective coping strategies. Nursing intervention would focus on helping the patient identify and use more adaptive coping strategies. Setting limits on the use of defense mechanisms is impossible. Values clarification might be unnecessary. Uncovering conflicts is not a focus of nursing intervention.
6. A patient approaches the nurse in the clinic waiting room and says, "I want to talk to you about a sexual matter." The nurse can best facilitate the discussion by providing which response? a. "Let's go to my office." b. "I want to help. Go ahead. I'm listening." c. "Let's schedule an appointment with more time." d. "Let's move to a private area in the waiting room."
ANS: A A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. Offering to schedule an appointment blocks communication.
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.
12. A soldier experienced a TBI associated with acceleration-deceleration forces. Which part of the neuron was most likely damaged? a) Axon b) Dendrite c) Telomere d) Cell body
ANS: A Acceleration-deceleration forces cause shearing of axons not dendrites, which result in TBIs. The cell body is not believed to be traumatized. Telomeres are part of DNA, not neurons.
12. A nurse realizes that the comment just made to a patient was inconsiderate. What is the nurse's most therapeutic statement in this situation? a. "How do you feel about what I just said?" b. "See, even nurses say stupid things sometimes." c. "Sorry about that. Let's continue where we left off." d. "That was an insensitive remark. I'm sorry if it hurt you."
ANS: A Acknowledging insensitivity and apologizing for it will usually repair damage. Patients usually evaluate the nurse on overall caring rather than on one single comment. None of the other options includes both acknowledgment and apology.
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.
5. A nurse finds a mental health care directive in the medical record of a patient experiencing psychosis. The directive prohibits the prescription of specific medications. Considering the patient's impaired function, what is the nurse's primary responsibility regarding medication administration? a. Ensure that the directives are respected in treatment planning. b. Review the directive with the patient to ensure that it is current. c. Alert the prescribing psychiatrist of the directive. d. Discuss the revision of the directive with the patient's guardian or power of attorney.
ANS: A Advance directives for psychiatric care given by competent patients are considered binding and should be respected in planning treatment. The patient is not currently capable of making such decisions due to the psychosis. The decision cannot be rescinded if it was appropriately arrived at a time when the patient was cognitive. Alerting the current prescribing psychiatrist is appropriate, but it is not the primary nursing responsibility at this time.
14. A community health nurse assesses four patients between ages 70 and 80. Which patient has the highest risk for alcohol dependence? a. Patient with no history of alcohol-related problems until retirement but now drinks alcohol daily to distract himself from arthritis pain. b. Patient who drank socially throughout adult life and continues this pattern, saying "I'm old enough to drink if I want to." c. Patient who abused alcohol between ages 30 and 45 but now abstains and occasionally attends AA meetings. d. Patient with intermittent problems of alcohol misuse early in life. Now drinks one glass of wine nightly with dinner.
ANS: A Alcohol dependence can develop at any age, and the geriatric population is particularly at risk. The geriatric problem drinker is defined as someone who has no history of alcohol-related problems but develops an alcohol abuse pattern in response to the stresses of aging.
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.
8. A nurse providing spiritual care for a patient awaiting a liver transplant demonstrates knowledge of anticipated spiritual needs by focusing on what area? a. Issues related to personal mortality b. The need for prayer and organized religion c. Misinterpretation of medical information regarding liver transplantation d. Techniques for minimizing clinical depression
ANS: A Although each of the options is possible, the most likely response is thinking about what the illness means in terms of life span, quality of life, and other mortality issues. The other responses are pathologic and are not seen as frequently.
3. A depressed patient expresses feelings of hopelessness, helplessness, and powerlessness. The patient's spiritual distress is best addressed by which nursing intervention? a. Assisting the patient find meaning and hope through making personal choices b. Encouraging the patient to develop wisdom in the face of adversity c. Assessing the patient in drawing strength from a higher power d. Identifying ways the patient can live by higher principles
ANS: A Although individuals cannot always choose their circumstances, they always have a choice of attitudes toward their experiences. Without finding meaning, individuals develop hopelessness. None of the other options relates directly to hopelessness.
2. A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I'll be glad when I can help someone else." This statement reflects what therapeutic factor? a. Altruism b. Universality c. Cohesiveness d. Corrective recapitulation
ANS: A Altruism refers to the experience of being helpful or useful to others, a condition that the patient anticipates will happen. The other options are also therapeutic factors identified by Yalom.
19. The nurse administers a medication that potentiates the action of noradrenaline. Which finding would be expected? a. Reduced anxiety b. Improved memory c. More organized thinking d. Fewer sensory perceptual alterations
ANS: A An animal model of chronic neuropathic pain was associated with impairment in the firing activity of the locus coeruleus and its expression of noradrenaline in ascending and descending pathways, which plays roles in not only pain perception, but also mood, anxiety, attention and concentration, the sympathetic nervous system, and the activity of the hypothalamic-pituitary-adrenal axis. Acetylcholine and substance P are associated with memory enhancement. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.
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.
10. A 10-year-old boy is diagnosed with gender identity disorder. Which assessment finding would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with other boys who are athletic d. Intense urges to watch his parents having sex
ANS: A An individual with gender identity disorder feels trapped in the body of the "wrong" gender and at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender identity disorder.
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.
3. An adult diagnosed with paranoid schizophrenia frequent experiences auditory hallucinations and walks about the unit, muttering. Which nursing action demonstrates the nurse's understanding of effective psychotherapeutic management of this client? a. Discussing the disease process of schizophrenia with the client and their domestic partner b. Minimizing contact between this patient and other patients to assure a stress free milieu c. Administering PRN medication when first observing the evidence that the client may be hallucinating d. Independently determining that behavior modification is appropriate to decrease the client's paranoid thoughts
ANS: A An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care by the care team.
15. The spouse of a patient with panic attacks tells the nurse, "I am afraid my husband has a permanent disorder and will have many hospitalizations in the future. I wonder how I will be able to raise our children alone." The nurse's reply should be based on which form of nursing knowledge? a. Psychopathology b. Milieu management c. Psychopharmacology d. Nursing relationship therapy
ANS: A An understanding of psychopathology will enable the nurse to communicate reassurance to the spouse regarding the treatment of panic attacks in an outpatient setting. None of the other options has psychotherapeutic knowledge of psychiatric disorders as its focus.
A patient who started a selective serotonin reuptake inhibitor (SSRI) 3 days ago says, "This medicine isn't working." The nurse's best intervention would be to: a. explain the time lag before antidepressants relieve symptoms. b. reassure the patient that the medication will be effective soon. c. critically assess the patient for lessening symptoms. d. explore the patient's self-concept.
ANS: A Antidepressant medications typically have a lag time of 2 to 4 weeks before being maximally therapeutic. A patient should be made aware of this instead of expecting symptom relief within 24 to 48 hours. Global reassurance is meaningless. Symptom abatement would not have occurred. Exploring the patient's self-concept does not address the patient's question.
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.
6. A patient constantly disrupts activities on an inpatient unit. Which action would place the nurse at risk of being quality of assault? a. Threatening to rescind the patient's weekend pass b. Placing the patient in seclusion c. Refusing to medicate the patient as prescribed d. Pushing the patient out of the day room
ANS: A Assault is defined as an act that creates a reasonable apprehension of harmful or offensive contact to another without consent of the other. The nurse has threatened the patient thus risking the risk of assault. Battery is unwanted touching such as pushing. Negligence is failure to do what is reasonably prudent under the circumstances such as not providing prescribed medications. False imprisonment is associated with unwarranted seclusion.
During an interview with a depressed person, it is important for the nurse to assess social interactions to determine: a. disruptions in relationships with others. b. needs for diversional activities therapy. c. needs for implementation of a no-harm contract. d. the patient's ability to make decisions about care.
ANS: A Assessing for altered social interactions will give the nurse information about whether relationships with significant others are intact or disrupted. Often, the depressed person has withdrawn to the extent that formerly supportive relationships have been disrupted, leaving the patient without situational support. Diversional activities are an integral part of management of the therapeutic milieu. The patient's ability to make decisions would be assessed in other ways. A no-harm contract relates to suicidal ideation.
Since admission, a patient diagnosed with antisocial personality disorder has been highly manipulative and constantly tests staff. Now, the patient insists on watching a late movie instead of complying with the bedtime. Select the nurse's best response. a. "It's a unit rule that bedtime is at 10 PM." b. "I will not allow you to manipulate me again." c. "If you ask again, tomorrow's bedtime will be 9 PM." d. "I understand your sleep problems and can allow it just this once."
ANS: A Attempts at manipulation can be successfully handled by firm, matter-of-fact reiteration of unit policies and consistently adhering to them. The other responses are defensive, retaliative, or permissive.
4. To help preserve patients' rights to freedom from restraint and seclusion, the most important interventions that the nurse can use are based on which intervention? a. Therapeutic management of the patient's needs b. Reality-based communication to minimize cognitive disorientation c. Confidentiality of all documentation associated with the patient d. Effective use of ancillary personnel to monitor the patient
ANS: A Attention to the nurse-patient relationship, the therapeutic milieu, and principles of pharmacologic management can reduce the need for restrictive measures. The other options are important aspects of care but do not relate directly to the use of restraint and seclusion.
13. An adult who exposed himself to a group on strangers tells the nurse, "I had just lost my job and was afraid; I just did it without thinking". Which intervention would have the greatest benefit for this person? a. Stress management b. Problem-solving c. Sex education d. Social skills
ANS: A Because the individual demonstrated the exhibitionistic behavior during a period of increased stress, providing stress management would be beneficial. The other interventions may be acceptable but would not have the relevance that stress management would have.
11. A child diagnosed with attention-deficit hyperactivity disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications prescribed to help manage the associated behaviors? a. Central nervous system stimulants b. Tricyclic antidepressants c. Antipsychotics d. Anxiolytics
ANS: A Central nervous system stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with A
9. A nurse notes abrasions on a baby's thighs and determines that skin scraping has been used by the parents. In an effort to use cultural negotiation, the nurse should implement which intervention? a. Encouraging the use of less pressure during scraping to prevent abrasions and infections b. Showing the parent how to use moxibustion rather than skin scraping c. Explaining that skin scraping does not effectively treat illness d. Cautioning that the scraped skin can become easily infected
ANS: A Cultural negotiation is the nurse's ability to work within a patient's cultural belief system to develop culturally appropriate interventions. Only by suggesting a modification of the technique of skin scraping so as to perform it in a manner that will not cause injury or the potential for infection can the nurse reflect cultural negotiation.
3. The nurse administers medications to a culturally diverse group of patients on a psychiatric unit. What expectation should the nurse have about pharmacokinetics? a. Patients of different cultural groups may metabolize medications at different rates. b. Metabolism of psychotropic medication is consistent among various cultural groups. c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications. d. It is important to provide patients with oral and written literature about their psychotropic medications.
ANS: A Cytochrome P-450 enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic medication; hepatic function influences metabolism rates. Information about medication is important but does not apply to pharmacokinetics.
13. A veteran with a suspected TBI is scheduled for diffusion tensor imaging (DTI). What information should the nurse provide? a) "This test will help show whether tracts in your central nervous system are damaged." b) "This test will measure changes in chemicals that transmit messages between your brain and spinal cord." c) "This test will help predict what types of medication will be effective for treating your symptoms." d) "This test will help your health care provider decide whether or not a computed tomography (CT) scan is needed to further diagnose your injuries."
ANS: A DTI is a form of magnetic resonance imaging that produces detailed microscopic images of neural tracts and related injuries. It provides better imaging of subtle injuries than CT scans. It does not measure neurotransmitters.
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.
8. A patient diagnosed with lung cancer continues to smoke and says, "I think my cancer is more the result of a bad gene than of smoking." The patient shows the use of which defense mechanism? a. Denial b. Compensation c. Intellectualization d. Reaction formation
ANS: A Denial is the unconscious refusal to admit an unacceptable idea or behavior, as shown in this example. Compensation refers to covering a weakness by overemphasizing a desirable trait. Intellectualization involves using a logical explanation without expressing emotion or affect. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.
6. An adult recently diagnosed with a mental illness is hospitalized with pneumonia. The patient and family are very anxious. What outcome should the nurse add to the plan of care for this family to meet their immediate needs? a. Identify and describe effective coping methods. b. Describe the stages of the anticipatory grieving process. c. Recognize the ways dysfunctional communication is expressed in the family. d. Examine previously unexpressed feelings related to the patient's sexuality.
ANS: A Desired outcomes might be set for the family as a whole or for individuals within the family. The outcome most closely associated with the anxiety that each is experiencing is to focus on identifying and describing ways of coping with the anxiety. The other options are not appropriate at this time.
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.
15. An older adult patient diagnosed with depression is prescribed a selective serotonin reuptake inhibitor (SSRI). Nursing assessment should include careful collection of what information to best assure patient safety? a. Other prescribed medications and over-the-counter remedies used b. Evidence of pseudo-parkinsonism or tardive dyskinesia c. History of psoriasis and other skin disorders d. History of diarrhea and electrolyte imbalances
ANS: A Drug interactions, both prescription and over-the-counter, can be problematic for the geriatric patient taking an SSRI. Careful collection of information is important. The distracters do not pose problems with SSRI drugs.
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.
4. A patient uses defense mechanisms excessively. The nurse should expect to find evidence that the patient is demonstrating what resulting effect? a. The patient has difficulty with problem-solving. b. The patient has an increased risk for psychosis. c. The patient's emotions are experienced with great intensity. d. The patient regularly denies reality.
ANS: A Excessive use of defense mechanisms results in the distortion of reality. When reality is not perceived accurately, problem-solving is impaired. The other options are not generally associated with defense mechanism use.
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.
11. A patient tells the nurse, "I make decisions each day that have a positive effect on my life." This statement is most closely related to what spiritual construct? a. Making meaning through choices b. A presence that orders the world c. Higher purpose and principles d. Higher power and achievement
ANS: A Frankl advocated that humans find meaning when they commit themselves to something beyond themselves. Making meaningful choices improves an individual's mental health. The constructs mentioned in the other options have less to do with the individual's decision making described in the scenario.
5. Which of Freud's contribution to psychiatry most affects current psychiatric nursing? a. The challenge to look at humans objectively b. Recognition of the importance of human sexuality c. Theories about the importance of sleep and dreams d. Discoveries about the effectiveness of free association
ANS: A Freud's work created a milieu for thinking about mental disorders in terms of the individual human mind. This called for therapists to look objectively at the individual, a principle that is basic to nursing. The correct answer is the most global response. Freud's theories of psychosexual development are an aspect of holistic nursing practice, but not the entire focus. Free association is not a pivotal issue in nursing practice.
2. Which documentation of family assessment indicates a healthy and functional family? a. Members provide mutual support. b. Power is distributed equally among all members. c. Members believe that there are specific causes for events. d. Under stress, members turn inward and become en
ANS: A Healthy families nurture and support their members, buffer against stress, and provide stability and cohesion. The distracters are unrelated to healthy family function or suggest incorrect dynamics.
14. A psychiatric nurse leads a medication education group for Hispanic outpatients. This nurse holds an analytic worldview and uses pamphlets as teaching tools while keeping sessions short and concise. After the group session, what conclusion will the patients most likely arrive at regarding the session based on their likely relational worldview? a. The nurse was uncaring. b. The session was effective. c. The teaching was efficient. d. They were treated respectfully.
ANS: A Hispanic individuals usually have a relational worldview. Their needs are for learning through verbal communication rather than reading and for having time to chat before approaching the task. An individual with a relational worldview would be unlikely to hold any of the other views.
20. Which patient would require careful assessment for toxic effects of lithium? The individual taking lithium and: a. hydrochlorothiazide (HCTZ). b. lorazepam (Ativan). c. clozapine (Clozaril). d. oxazepam (Serax).
ANS: A Hydrochlorothiazide is a diuretic used to treat hypertension. The diuretic effect would increase serum concentrations of lithium, potentially producing toxicity. Benzodiazepine and antipsychotic drugs are commonly used concurrently with lithium to control mania.
18. A nurse assesses a 25-year-old man with a suspected eating disorder. Which comment is most likely from this patient when the nurse asks about the patient's sexuality? a. "I just don't have much of a sex drive anymore." b. "I'm here because my girlfriend is worried about how much I exercise." c. "I am sexually active, but I sometimes have trouble maintaining an erection." d. "I've been involved in a satisfying relationship with my girlfriend for 3 years."
ANS: A In anorectic men, low sex drive and low testosterone levels might be the equivalent of amenorrhea in female patients. None of the remaining options reflect this concern.
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.
4. While volunteering at a homeless shelter, a nurse observes a known pedophile leaving the restroom with a small child. Select the nurse's priority action. a. Report the observation to authorities by the child abuse hotline. b. Protect the child without interacting with the perpetrator. c. Notify staff of the homeless shelter to address the situation. d. Continue to observe the interaction and document findings.
ANS: A In every state, nurses are mandated reporters of child abuse. The nurse is obligated legally and morally to report the incident so that proper authorities can follow up. The distracters do not fulfill the nurse's ethical or legal responsibilities.
4. During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best nursing response to this nonverbal cue. a. "I notice you keep looking toward the door." b. "This is our time together. No one is going to interrupt us." c. "It looks as if you are eager to end our discussion for today." d. "If you are uncomfortable in this room, we can move someplace else."
ANS: A Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.
17. A patient, who reported being raped 2 hours ago, provides a medical history and assessment coherently, quietly, and calmly in a monotone voice. How should the nurse assess this behavior? a. A delayed reaction to the trauma b. Indicative of ego integrity c. Evidence she is denying the rape occurred d. Employment of the defense mechanism of sublimation
ANS: A In the impact stage of trauma response, the individual might appear quite normal because the reality of the attack has not yet "registered." The emotional response might be delayed for hours or even days. The other options are not plausible. In psychology, sublimation is a mature type of defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior; denial is evidenced by a complete rejection that the event ever occurred. Ego integrity would indicate the client has accepted the event and moved on with life.
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.
21. What is the best analysis of this described nurse-patient interaction? Patient: I get discouraged when I realize I've been struggling with my problems for over a year. Nurse: Yes you have, but many people take even longer to resolve their issues. You shouldn't be so hard on yourself. a. The nurse has responded ineffectively to the patient's concerns. b. The patient is expressing lack of willingness to collaborate with the nurse. c. The patient is offering the opportunity for the nurse to revise the plan of care. d. The nurse is using techniques that are consistent with the evaluation step of the nursing process.
ANS: A In this response, the nurse has minimized the patient's feelings and problems, used clichés, and given advice—all considered ineffective responses. None of the other options provides an accurate assessment of the interaction.
11. A crisis team led by a psychiatric nurse assesses a patient with a history of paranoid schizophrenia who is standing on the lawn shouting, "Don't come near me. People are poisoning my water." Which statement made to the police officer accurately identifies the patient's immediate needs? a. "We've identified that this patient requires immediate emergency care." b. "This patient will require a hearing to implement a long-term commitment." c. "Please arrange for a probable-cause hearing for this patient." d. "This patient meets the criteria for short-term observation and treatment.
ANS: A Individuals who are deemed to be dangerous to self, dangerous to others as is possible with this patient, or those who are gravely disabled can be detained involuntarily for evaluation and emergency treatment for a specified period of time (often for 72 hours). Long-term commitment might be unnecessary. A probable-cause hearing is needed only for short-term observation and treatment.
17. The clinic nurse sees a new patient with vague sexual complaints. Select the best question for the nurse to help the patient express these concerns more clearly. a. "What are your concerns and feelings about your sexuality?" b. "Patients are frequently embarrassed to talk about sexuality." c. "Don't be embarrassed. Our conversation is completely private." d. "As a clinician, I am accustomed to talking to patients about personal matters."
ANS: A Individuals with sexual concerns may need help and support to express the problem. Approaching the subject directly is most appropriate. The patient is not concerned with the problems of other patients or the nurse's level of comfort.
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. A patient diagnosed with bipolar disorder asks the nurse, "Why can't I take my lithium just once a day at bedtime? It's hard to remember to take it three times." The nurse's reply should be based on what information? a. The half-life of lithium is short. b. Renal excretion is greater at night. c. GI absorption is diminished at night. d. The toxicity potential increases with once-a-day dosing.
ANS: A Lithium has a short half-life, high toxicity, and rapid renal excretion, so multiple daily doses are required. The other statements are incorrect or are not factors considered in dosing.
11. The nurse scheduling the serum lithium level blood draw for a patient should arrange for it to be obtained: a. before the first morning dose. b. 2 hours after the morning dose. c. at bedtime. d. any time during the day.
ANS: A Lithium levels should be drawn 8 to 12 hours after the last dose, making premedication morning blood draws optimal.
16. A combat veteran with TBI, depression, and anxiety begins new prescriptions for sertraline (Zoloft) and lorazepam (Ativan). In recognition of potential long-term repercussions, the nurse should provide teaching related to which topic? a) Nonpharmacologic strategies for managing anxiety b) Identifying signs and symptoms of hepatotoxicity c) Recognizing evidence of tardive dyskinesia d) Strategies for preventing obesity
ANS: A Lorazepam is a benzodiazepine, which has a high probability of causing dependence if taken long term. The nurse should teach nonpharmacologic strategies for managing anxiety to facilitate the patient's readiness to discontinue the lorazepam. Tardive dyskinesia is associated with antipsychotic drugs. Weight gain is associated with atypical antipsychotic drugs. Hepatotoxicity is not a likely complication.
6. General George Patton led U.S. troops in Europe and Africa during World War II. His career was marred by an incident of scolding a distressed, frightened soldier as "a coward" and "yellow." Patton's behavior embodied which phenomenon associated with symptom delay in PTSD? a) Stigma b) Lag time c) Obscuration d) Co-morbidity
ANS: A Many soldiers and veterans fight the symptoms of mental illness associated with combat. They fear appearing weak or inadequate. These phenomena contribute to the stigma associated with war-related psychiatric illnesses.
11. The nurse is preparing a care plan for a client who experienced abuse by a domestic partner. It is most important to include a long-term outcome that addresses what client need? a. Moving from the individual from victim to survivor status b. Providing a support groups for emotional assistance c. Using empathy to establish rapport and build trust d. Shifting blame for the incident from patient to perpetrator
ANS: A Moving from victim to survivor status is a process that can go on for months to years. It involves integrating the memories of the trauma and moving on in life with restored functioning, a reasonable sense of safety and security, healthy relationships, and improved self-esteem. The other needs can usually be met in the short term.
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.
7. Which statement most accurately describes a nurse's role regarding psychopharmacology? a. "You will need to frequently make decisions regarding the administration of PRN medications to help the client manage anger." b. "It's a nursing responsibility to adjust a medication dose to assure effective patient responses." c. "Nurses administers medications while evaluating drug effectiveness is a medical responsibility." d. "To best assure appropriate response, a patient's questions about drug therapy should be referred to the psychiatrist."
ANS: A Nursing assessment and analysis of data might suggest the need for PRN medication as patient anxiety increases or psychotic symptoms become more acute. The nurse is the health team member who makes this determination. Nurses are responsible for monitoring drug effectiveness as well as administering medication. Nurses should assume responsibility for teaching patients about the side effects of medications. Nurses cannot alter prescribed dosages of medications unless they have prescriptive privileges.
This nursing diagnosis is documented for a depressed patient: situational low self-esteem, related to recent divorce, as evidenced by self-deprecatory statements and blaming self for marriage failure. Identify the best short-term outcome. Within 4 days, the patient will: a. state that both partners had faults for the failed marriage. b. express angry feelings toward the estranged spouse. c. list expected effects of antidepressant medication. d. have significantly improved self-esteem.
ANS: A Outcomes should target the assessment findings and be measurable; in this instance, self-blame and self-deprecation. Progress will be evident when the patient is able to state that both partners had faults in the marriage. Expressing angry feelings toward the spouse does not relate directly to the patient's self-blame. An improved self-esteem is not measurable as stated. Antidepressant medication is unrelated to the diagnosis.
4. When is it most important for the nurse to screen for signs and symptoms of post-combat PTSD? a) Screening should be ongoing b) Before departing to return to the United States c) Immediately upon return from the combat zone d) One year after returning from the combat experience
ANS: A PTSD can have a very long lag time; in some instances, it can be 20 years or more. Screening should be ongoing. The other options are too limited.
10. What is a realistic outcome for group members of a psychoeducational group? a. Discuss ways to manage their illness. b. Develop a high level of trust and cohesiveness. c. Understand unconscious motivation for behavior. d. Demonstrate insight about development of their illness.
ANS: A Patients have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.
15. A patient who is to be discharged on a maintenance dose of lithium should be taught to report which symptoms/signs immediately? a. Large amounts of dilute urine and blurred vision b. Nasal congestion and dry mouth c. Muscle stiffness and anorexia d. Drowsiness and sweating
ANS: A Patients must be taught the difference between symptoms of minor toxicity and those of major toxicity, such as giddiness, tinnitus, blurred vision, dilute urine, and ataxia.
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
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.
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.
19. One bed is available on the inpatient eating disorders unit. Assessment findings for four patients are listed as follows. Which patient has priority for admission? a. Weight decreased from 150 to 102 lb in 4 months. Vital signs are T 96.9°F; P 46 beats/min; BP 68/48 mm Hg. Amenorrhea for 8 months. b. Weight decreased from 110 to 86 lb in 4 months. Vital signs are T 97.5°F; P 60 beats/min; BP 80/66 mm Hg. Amenorrhea for 2 months. c. Weight decreased from 120 to 90 lb in 3 months. Vital signs are T 98°F; P 50 beats/min; BP 70/50 mm Hg. Menstruation scant for 3 months. d. Weight decreased from 90 to 78 lb in 5 months. Vital signs are T 97.7°F; P 62 beats/min; BP 74/52 mm Hg. Menstruation irregular for 6 months.
ANS: A Physical findings indicative of an acute status include amenorrhea for 3 consecutive menstrual cycles, weight loss more than 30% of body weight within 6 months, hypothermia, pulse less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.
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.
23. When preparing to lead an anger management group, the nurse is demonstrating knowledge in what type of group? a. Psychoeducational b. Self-help c. Activity d. Support
ANS: A Psychoeducational groups include anger management, relapse prevention, medication education, and living skills.
12. A Chinese-American infant is seen in a well-baby clinic. The parent reports that the baby is irritable and not eating well. The nurse notices several skin abrasions on the thighs and upper arms. What is the nurse's most appropriate initial intervention? a. Ask if the parent has used coining on their child. b. Report the parent for suspected child abuse. c. Assess whether the parent desires to harm the child. d. Ask if the parent has taken the child to an acupuncturist.
ANS: A Recognition of the characteristic marks of coining or skin scraping can keep the nurse from making a culturally insensitive judgment that child abuse is occurring. Coining is used by Asian families to restore equilibrium for babies and small children. The other options would be inappropriate or ineffective.
16. Teaching for a patient who is to be discharged on a maintenance dose of lithium should emphasize the importance of: a. keeping appointments for serum lithium level testing. b. engaging in daily cardiotonic exercise. c. reporting anticholinergic side effects. d. maintaining a tyramine-free diet.
ANS: A Regular evaluation of serum lithium levels will be part of the patient's aftercare for as long as he or she takes lithium. The other items are not included in discharge teaching for a patient taking lithium.
22. A nurse engaging in which behavior demonstrates a need for addition education regarding the release of patient information without expressed written consent? a. Providing the estimated date of discharge to the patient's employer b. Documenting the patient's daily behaviors during hospitalization c. Discussing the patient's history with other team members during care planning d. Documenting in the medical record the date and circumstances information was released to the court system
ANS: A Release of information to individuals or entities without patient authorization violates the patient's right to privacy. Documentation is a nursing responsibility and both the treatment care team and the court have the right to access such information.
15. A nurse cares for a patient demonstrating paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors by decreasing libido? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic d. Mood stabilizer
ANS: A SSRIs are reported to have a positive effect on paraphilia since they can cause decreased libido, impair orgasms, and interfere with ejaculation. The other medications are not indicated for this disorder.
In planning care for a newly admitted patient with depression, what is the nurse's highest priority? a. Providing a safe environment b. Encouraging expression of feelings c. Orienting the patient to the unit milieu d. Meeting the patient at an appropriate affective level
ANS: A Safety is the highest priority. The other interventions are appropriate but of lesser importance than this basic need.
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.
4. A survivor of childhood abuse is hospitalized following an episode of wrist cutting. The patient has a history of binge/purge eating disorder as well as difficulty trusting and relating to others. What is the nurse's priority intervention? a. Set limits on self-harmful behavior. b. Foster belief in and valuing of family unity. c. Confront abnormal eating patterns and self-mutilation. d. Encourage discussion of personal responsibilities associated with abuse.
ANS: A Setting limits on self-mutilating behavior or purging is necessary to provide for the safety needs of the patient. Individuation should be fostered. The victim should not be encouraged to accept any personal responsibility for the abuse. The patient is aware of the eating patterns and self-mutilation; confrontation will not build trust.
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.
14. Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? a. The child has been raised by a parent with chronic major depression. b. The child's best friend has developed a chronic illness c. The child was not promoted to the next grade one year. d. The child moved to three new homes over a 2-year period.
ANS: A Statistics indicate that children raised by a depressed parent have an increased risk of developing an emotional disorder. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk enhancing.
13. A newly admitted patient is experiencing a manic episode. The patient is verbally and physically aggressive. The plan for care should include: a. setting clear limits, providing a quiet environment, and limiting activities. b. avoiding use of antipsychotic drugs for 24 hours and providing nourishment ad lib. c. orienting to unit activities, encouraging gross motor activity, and watching television. d. avoiding confrontations by not enforcing limits and encouraging physical exercise at bedtime.
ANS: A Stimuli should be reduced to provide a simple, quiet, and nonstimulating environment. Clear limits should be explained in as few words as possible, and then maintained. Gross motor activity should be limited to prevent exhaustion, and exercise should not be encouraged at bedtime. Quiet activity is more conducive to initiating sleep. Intake should be monitored and food and fluids encouraged to compensate for the higher energy expenditure of the patient. Antipsychotic drugs will probably be needed to reduce activity and aggressiveness.
17. The parent of an adopted infant tells the nurse, "Our baby was abused before the adoption. I read an article online that said this experience causes problems as a child grows up. What we should be watching for?" Select the nurse's best response. a. "Early trauma sometimes causes learning difficulties, anxiety, and difficulty handling stress later in life." b. "Early abuse causes the myelin covering of the nerves to overgrow, which leads to high anxiety and mood instability." c. "Many individuals who experience early trauma and abuse develop symptoms of schizophrenia." d. "Your child will be normal. Information in online articles is not reliable."
ANS: A Stress increases cortisol levels. Excessive cortisol levels can cause hippocampal atrophy, leading to memory and learning difficulty. Elevated cortisol level is also associated with hypersensitivity of the hypothalamic-pituitary-adrenal (HPA) system, leading to overreaction to stress and possibly a propensity to depression and anxiety. Myelin continues to grow after birth, but overgrowth is not likely as a result of abuse. Stating that the individual is at risk for schizophrenia is incorrect. Online articles may or may not be reliable. The nurse should not give false reassurance about the child's development.
21. A student nurse says, "I don't need to interact with my patients. I learn by observing them." The instructor can best interpret the nursing implications of Sullivan theory to this student by responding which statement? a. "Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." b. "Observing patient interactions can help you formulate priority nursing diagnoses and appropriate interventions." c. "I wonder how accurate your assessment of the patient's needs can be if you do not interact with the patient." d. "It is important to note patient behavioral changes because these signify changes in personality."
ANS: A Sullivan believed that the nurse's role includes educating patients and assisting them in developing effective interpersonal relationships. Mutuality, respect for the patient, unconditional acceptance, and empathy are cornerstones of Sullivan theory. These cornerstones cannot be demonstrated by the nurse who does not interact with the patient. Observations provide only objective data. Priority nursing diagnoses usually cannot be accurately established without subjective data from the patient. The other distracters relate to Maslow theory and behavioral theory.
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.
7. A child being treated for which medication has a high risk for suicide and should be monitored closely? a. Depression with fluoxetine b. ADHD with methylphenidate c. Bipolar disorder with aripiprazole d. Asperger disorder with social skills training
ANS: A The child being treated for depression with fluoxetine is at risk for behavioral activation, a drug side effect. Increased suicide risk is part of the behavioral activation complex. The drugs mentioned in the other options do not place the individual in the same risk category as fluoxetine. D
6. Which patient should be assessed most carefully for evidence of lithium toxicity? A patient taking lithium (Lithobid) and: a. indomethacin (Indocin). b. risperidone (Risperdal). c. ziprasidone (Geodon). d. olanzapine (Zyprexa).
ANS: A The combination of lithium and indomethacin is more likely to produce lithium toxicity than lithium and any other drug listed. Nonsteroidal antiinflammatory drugs reduce renal elimination of lithium, thereby increasing serum lithium levels.
Which entry in the medical record best indicates that the treatment plan for a depressed patient was successful? a. Gained 2 pounds; sleeping 8 hours nightly; states, "I'm feeling better about my life situation." b. Weight stable; sleeping 6 hours nightly; complains of frequent abdominal pain and headache. c. Gained 6 pounds; sleeping 10 hours nightly; sensitive to interpersonal conflicts. d. Lost 2 pounds; sleeping 5 hours nightly; shows minimal interest in activities.
ANS: A The correct entry suggests that weight, sleep pattern, and mood are returning to normal. The other entries suggest that symptoms of depression continue to be present.
10. Which comment by the nurse would best support relationship building with a client who has experienced partner abuse? a. "It's normal to feel violated, because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I'm very worried about you. I know you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."
ANS: A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship build on acceptance. None of the other options would help the patient feel accepted.
11. When a nurse working in a well-child clinic asks a parent's address, the parent responds, "My children and I are homeless." What assumption should the nurse make of this response? a. It is a common occurrence, because 1 out of 50 children are homeless. b. It signals a need to investigate the possibility that the parent has severe mental illness. c. Confirms that evidence of child abuse or neglect that should be reported to social service agencies. d. Suggests that the parent may have substance abuse problem.
ANS: A The current belief is that the homeless are people (including entire families) who have been displaced by social policies over which they have no control. One out of 50 children is homeless. Although homelessness might be associated with serious mental illness, it might also be the result of having a weak support system and of social policies over which the individual or family has no control. No assumption should be made about the existence of child or substance abuse.
18. For patients with bipolar disorder, valproate anticonvulsants are likely to help control rapid-cycling episodes by: a. inhibition of kindling activity in the brain. b. decreasing availability of norepinephrine. c. increasing dopamine levels at synapses. d. decreasing GABA metabolism.
ANS: A The effectiveness of valproate anticonvulsants for management of bipolar disorder may be related to inhibition of kindling activity, which stabilizes neuronal activity and increases the threshold of stimulation necessary for cell firing. There is no current research to support any of the other options.
2. A nurse plans an intervention to support a patient's ego. What makes supporting ego a therapeutic intervention? a. It provides rational, logical reality testing. b. It is primarily concerned with right and wrong. c. It uses primary process imagery to meet basic needs. d. It is derived from the individual's pattern of thinking.
ANS: A The ego focuses on the reality principle and uses secondary-process thinking, a logical, rational operation to maintain the well-being of the individual. The superego is concerned with right and wrong. The id uses primary process. Ego formation is influenced by heredity, environment, and maturation.
Which adolescent would the nurse consider to have the highest priority for health promotion interventions aimed at reducing risk for depression? An adolescent whose history shows: a. parents were killed in an auto accident. b. lived with adoptive parents since birth. c. allergies to dust, pollen, and mold. d. frequent conflicts with siblings.
ANS: A The events that predispose children and adolescents to develop depression involve loss such as death or separation from parents, death of a close relative, death of a pet, a move to another neighborhood, academic problems, or illness or injury that requires hospitalization. It is the only answer that reflects the relationship of loss to the disorder.
13. A patient who experiences frequent panic attacks asks the nurse, "Why does this happen to me?" The nurse should explain that the problem might relate to a deficit of which brain chemical? a. Noradrenaline b. Serotonin c. Dopamine d. Glutamate
ANS: A The firing activity of the locus coeruleus and its expression of noradrenaline in ascending and descending pathways plays a role in not only pain perception, but also mood, anxiety, attention, and concentration, the sympathetic nervous system, and the activity of the hypothalamic-pituitary-adrenal axis. The other options have not been suggested as factors by research studies. D
15. When a nurse uses the interpersonal model as a basis for practice, which goal is most appropriate for the patient care plan? a. The patient will develop mature, satisfying relationships that are relatively free of anxiety. b. The patient will rid himself of irrational beliefs, including "shoulds," "oughts," and "musts." c. The patient will learn to meet basic needs responsibly. d. The patient will manage stress adaptively.
ANS: A The goal of interpersonal therapists is to assist the patient in developing healthy interpersonal relationships that are relatively anxiety-free. The other distracters state a goal appropriate for cognitive therapy, reality therapy, and stress management therapy, respectively.
22. When explaining risk assessment, the nurse would indicate that the highest priority for admission to hospital-based care is associated with which goal? a. Safety of self and others b. Minimal confusion and disorientation c. Successful withdrawal from harmful substances d. Management of medical illness complicating a psychi
ANS: A The highest priority is safety. In the other situations, threats to safety might or might not exist.
Patients diagnosed with dependent personality disorders behave submissively and cling to others. What is the best explanation of this behavior? a. The patients are afraid of being alone or functioning without direction. b. The patients adhere to strict standards and fear failure. c. The patients have little regard for the rights of others. d. The patients are suspicious of the motives of others.
ANS: A The individual with a dependent personality disorder has a pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviors. The other options are characteristic of individuals with obsessive-compulsive personality disorder, antisocial personality disorder, and paranoid personality disorder.
20. Which comment should the leader of a newly formed group include in the initial meeting? a. "It is important for everyone to arrive on time for our group." b. "Talking to family members about our group will help us achieve our goals." c. "Everyone is expected to share a personal experience at each group meeting." d. "Groups provide more cost-effective treatment in this time of budget constraints."
ANS: A The leader must set ground rules for the group before members can effectively participate. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. Although groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.
19. Which comment would be most appropriate for the group leader to begin the discussion at the first meeting of a new group? a. "Let's start by establishing some rules for our group." b. "Let's begin with each person here defining his or her problem." c. "I want each person to explain why he or she is attending this group." d. "Talking to family about our group will help us achieve our goals."
ANS: A The leader must set ground rules for the group before members can effectively participate. Bringing family members would jeopardize confidentiality. Members share feelings after the group develops an identity and cohesiveness.
21. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate to a patient diagnosed with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop. I don't want to take that medicine anymore. I hate the side effects." What action should the nurse take? a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Proceed with the injection but explain to the patient that there are medications that may help reduce the unpleasant side effects. c. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose." d. Notify other staff to report to the room for a show of force, and proceed with the injection, using restraint if necessary.
ANS: A The nurse, as an advocate and educator, should seek more information about the patient's decision and should not force the medication. Patients with mental illness retain their civil rights unless there is clear, cogent, and convincing evidence of dangerousness. The patient in this situation presents no evidence of dangerousness. It is not reasonable to promise a reduction in side effects without first discussing them, nor is it appropriate to pressure the patient into taking the medication. The medication cannot be given without the patient's informed consent.
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.
6. A young adult who has few interpersonal relationships, says, "Most people can't be trusted." This person makes decisions only after consulting with his parents. Using Erikson developmental theory, the nurse can draw which conclusion? a. The patient has evidence of inferiority and lacks a sense of direction. b. Developmental deficits in early life have impaired the patient's adult functioning. c. The patient's developmental problems will probably lead to a serious mental illness. d. It is impossible for the patient to proceed to the next developmental stage until mastering earlier stages.
ANS: A The patient achieved only partial mastery of the trust-versus-mistrust stage. Deficits in development carried from one stage to the next interfere with functioning at the adult level. Individuals do progress from stage to stage when mastery is not attained; however, adjustment is usually impaired. Developmental problems might lead to a serious mental disorder but might also produce less serious results.
11. A Hispanic patient reports symptoms consistent with the cultural phenomena of susto. A physical examination reveals no pathology, and depression is diagnosed. The effectiveness of selective serotonin reuptake inhibitors (SSRIs) may be increased if combined with what cultural intervention? a. A traditional healer b. Acupuncture c. Skin scraping d. Moxibustion
ANS: A The patient is probably experiencing lost soul, a culture-bound illness. Its symptoms are depressive in nature and might well respond to treatment with an antidepressant. However, because the individual sees the cause as loss of the soul, she will not have faith in medication as a cure. Using a traditional healer to return the lost soul will set the stage for medication to relieve symptoms. The other options are not culturally appropriate.
7. A male victim of gang rape comes to the emergency department. The victim is severely anxious, but the nurse will not be able to care for the patient for at least 20 minutes based on the current patient load. How can the nurse best meet the client's needs? a. Assigning a female nursing assistant to remain with the patient in a private cubicle b. Assigning a male nursing assistant to help the patient undress in a private cubicle c. Directing hospital security personnel to monitor the patient in the waiting room d. Notifying law enforcement authorities of the situation immediately
ANS: A The patient should be moved from the waiting room to a cubicle as quickly as possible. He needs the reassuring presence of a woman who can reduce the fear of further sexual abuse. Assigning a man would probably increase his anxiety to panic level. The initial priority would be to care for the patient rather than notifying law enforcement.
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.
24. A patient's insurance will not pay for continuing hospitalization at a private facility, so the family considers transferring the patient to a public psychiatric hospital. They express concern that the patient will "never get any treatment." Select the nurse's most helpful reply to their concern. a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern, because the right to treatment extends only to provision of food, shelter, and safety." c. "Much will depend on other patients, because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."
ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals under federal law. The remaining statements do not accurately describe that right.
7. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, but I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind." The soldier is describing which phenomenon associated with PTSD? a) Reexperiencing b) Hyperarousal c) Avoidance d) Psychosis
ANS: A The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.
13. A patient has mild lithium toxicity with a serum level of 1.6 mEq/L. Which assessment findings are most likely? a. Coarse hand tremor, coordination problems, and dizziness b. Elevated white blood cell count, temperature, and blood pressure c. Orthostatic hypotension, fainting, and nystagmus d. Restlessness, shuffling gait, and tics
ANS: A The symptoms of mild toxicity are often related to central nervous system disturbance. Difficulty concentrating might also be noted. Mild GI disturbances are also seen. The other options are not symptoms of early lithium toxicity.
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.
22. A patient says to the nurse, "I dreamed I could not breathe and was being attacked. When I woke up, I felt emotionally drained, as though I hadn't rested at all." Which comment would be appropriate if the nurse seeks to interpret the patient's experience? a. "It sounds as though you were uncomfortable with the content of your dream." b. "So you are saying that you were not able to breathe and felt in danger?" c. "I understand. Thank you for telling me about your bad dream." d. "So, you feel as though you had a poor night's sleep?"
ANS: A The technique of interpreting is therapeutic and helps the nurse examine meaning and importance of the experience. The distracters use other techniques.
15. A patient demonstrates a problem identifying odors. The nurse can project that there is dysfunction in which cerebral lobe? a. Temporal b. Parietal c. Occipital d. Frontal
ANS: A The temporal lobes are divided into pre-olfactory and olfactory areas for odor detection and processing. A parietal lobe lesion would involve sensory interpretation or association. An occipital lobe lesion would produce loss of vision. Problems with the frontal lobe would produce motor problems or changes in thought or personality.
1. The patient says, "I know I'm very sick right now, but I trust that God will make me better." Based on this statement, the nurse can assess the patient's spirituality as being based on what model? a. Theism b. Humanism c. Behaviorism d. Existentialism
ANS: A Theism is the only model that suggests that people are inextricably tied to a transcendent being. This view provides hope for a better future. None of the other views have this basis.
5. Effective use of the nursing process is dependent on communication that demonstrates what? a. Structure and goal-direction b. Meeting the needs of both patient and nurse c. Being spontaneous and affording mutual self-disclosure d. Fostering emotional distance between patient and nurse
ANS: A Therapeutic communication occurs with the purpose of helping patients. It is patient-centered, structured, and goal-directed. It is not expected to meet the needs of the nurse or to include mutual self-disclosure. These are characteristics of social communication. The nurse maintains objectivity, rather than emotional distance.
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.
7. Which information is most important to obtain during assessment of an older adult with a mental disorder? a. Functional ability and emotional status b. Chronologic age and sexual functioning c. Economic status and sources of income d. Developmental history, interests, and activities
ANS: A These data provide an overview of patient problems and ability to function. They guide the selection of interventions and services to meet identified needs. The other options reflect information of relevance but are not of highest priority.
3. A patient is hospitalized with new onset of manic behavior. It would be important for the nurse to inspect and report results of which laboratory tests? Select all that apply. a. Calcium b. Creatinine c. Potassium d. Drug screens e. Thyroid function
ANS: A, D, E Medical conditions may cause mania, including hypercalcemia, hyperthyroidism, and selected drugs of abuse, particularly stimulants. Steroids may also produce mania.
14. Which skill is most important to a nurse working as a member of a community mental health team that strives to use a seamless continuum of care? a. Case management b. Diagnostic ability c. Physical assessment skills d. Patients' rights advocacy
ANS: A To effectively use a seamless continuum of care, a nurse must have case management skills with which he or she can coordinate care using available and appropriate community resources. Psychosocial assessment and physical assessment are functions that can be fulfilled by another health care worker. Patients' rights advocacy is one aspect of case management.
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.
10. When a hyperactive, aggressive patient with bipolar disorder threatens to beat up another patient, the initial nursing intervention should be to: a. provide firm verbal limits. b. place the patient in seclusion. c. ask the patient, "Why are you so angry?" d. distract the patient with diversional activities.
ANS: A Unless a physical attack has taken place, verbal limit-setting should precede the use of more restrictive measures.
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.
6. A patient is withdrawn, suspicious, and maintains physical distance from staff and other patients. Which intervention demonstrates appropriate use of touch with this patient? a. Refraining from touch without first obtaining permission b. Patting the patient's arm when fear is expressed c. Reaching out to shake the patient's hand as an initial greeting d. Placing an arm around the patient's shoulders while walking down the hall
ANS: A Withdrawn, suspicious patients often consider touch a violation of personal space or might misinterpret touch as being sexual or aggressive. Refraining from touching a suspicious patient is wise until there is evidence that the patient can tolerate touch. The more intimate or extensive the touching, the more threatening it might be to the patient.
2. A school nurse uses a participative approach to teach about safety to a group of third graders. Which questions should the nurse pose to the students? (Select all that apply.) a. "What would you do if a stranger told you to get in his or her car because your parents were hurt?" b. "If you were playing on the Internet, and someone invited you into a private chat room, what would you do?" c. "If your parents told you that your pet was hurt, would you go with them to the veterinarian?" d. "Has anyone ever touched you in a way that embarrassed or frightened you?" e. "Which members of your family can you trust?"
ANS: A, B Teaching about the risk of sexual misconduct is important for school-age children. Trickery, bribes, and the Internet are sources of potential danger. It would not be appropriate to ask students in a group setting if they had been inappropriately touched or which family members were trustworthy.
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.
3. A nurse assesses a patient recently diagnosed with pedophilia. Which assessment findings are most likely to be identified? (Select all that apply.) a. History of childhood sexual abuse b. Antisocial personality traits c. Limbic system abnormalities d. An endocrine disorder e. Grandiosity
ANS: A, B, C Pedophiles commonly have a history of sexual abuse, limbic system abnormalities, and traits of some personality disorders. Endocrine problems are not associated with pedophilia. Self-confidence is lacking; grandiosity would not be expected.
Which behaviors create interpersonal relationship problems for an individual diagnosed with narcissistic personality disorder? Select all that apply. a. Grandiose self-importance b. Sense of entitlement c. Lack of empathy d. Risk taking e. Shyness
ANS: A, B, C The individual with narcissistic personality disorder has difficult interpersonal relationships because of characteristic behaviors and tendencies toward grandiose self-importance, a sense of entitlement, and lack of empathy. Evidence does not suggest the other characteristics as behaviors or traits of individuals with this personality disorder
1. Which behaviors are indicative of bullying by a child? (Select all that apply.) a. Recruits other children to avoid a child who wears glasses. b. Consistently calls another child "fat" and "stupid." c. Trips another children, because "it's fun." d. Repeatedly steals another child's lunch money. e. Plays a practical joke on another child.
ANS: A, B, C, D Bullying can be verbal, relational, or physical. It is repetitive and intentionally produces harm or pain in another person. Playful teasing, one-time aggression, and joking do not meet the criteria for bullying.
1. Which assessment findings related to the same patient help confirm a diagnosis of anorexia nervosa? (Select all that apply.) a. Patient reports amenorrhea for 9 months b. Patient is 5 feet 4 inches tall and weighs 85 lb c. Blood pressure (BP) 70/42 mm Hg d. Skin turgor is poor e. Pulse 68 beats/min
ANS: A, B, C, D Data confirming amenorrhea, low weight related to height, hypotension and poor skin turgor are consistent with the medical diagnosis of anorexia nervosa. A pulse rate of 68 beats/min is low normal.
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.
1. After a parent is hospitalized with severe depression, family members say, "We're falling apart. Nobody knows what to expect, who should make decisions, or what to do to keep the family together." Which interventions should the nurse include in the plan of care for this family? (Select all that apply.) a. Help the family set realistic expectations. b. Provide empathy, acceptance, and support. c. Empower the family by teaching problem-solving. d. Negotiate role flexibility among family members. e. Focus on the family rather than on the patient in planning.
ANS: A, B, C, D The correct answers address expressed needs of the family. The other option is inappropriate since the issues relate to the entire family and so much include all family member's to the degree they are capable of participating.
2. A new nurse asks the mentor, "How can I help meet patients' spiritual needs?" What personal characteristics should the mentor focus upon? (Select all that apply.) a. Being authentic b. Being respectful c. Demonstrating caring d. Speaking slowly and concretely e. Ability to answers theological questions
ANS: A, B, C, D The needs elicited from patients (authenticity, caring, respect) can be seen as caregiver behaviors that enhance trust formation. The need to speak slowly and in concrete terms is important for patients with thought disorders who have cognitive problems that make comprehension slower and abstraction difficult to understand. Answering theological questions is not a focus in this situation.
2. Which terms have historically been applied to soldiers suffering psychiatric distress related to exposure to the horrors of war? Select all that apply. a) Shell shock b) Battle fatigue c) Soldier's heart d) Cyclothymic disorder e) PTSD
ANS: A, B, C, E Soldier's heart, shell shock, battle fatigue, and PTSD are terms that have been used over time to describe psychiatric distress related to exposure to the horrors of war. Cyclothymic disorder is an affective disturbance not related to traumatic experiences.
1. Which interventions should the nurse implement to facilitate an effective assessment of an older adult? (Select all that apply.) a. Allow time for client to formulate answers. b. Use open-ended questions to encourage conversation. c. Ensure privacy to help minimize unwillingness to share information. d. Speak loudly to assure client's ability to hear the questions clearly. e. Explain the purpose of the assessment.
ANS: A, B, C, E The general rules of interviewing apply. In addition, older adults respond better to open-ended questions than to a barrage of direct questions. Because it might take the older adult longer to formulate an answer, the nurse should allow time for the patient to answer. Making sure that the patient uses his or her glasses and hearing aid is advisable. Information should be obtained directly from the patient if possible. Direct questions might seem intrusive. Speaking loudly is necessary only if the patient has a hearing deficit. Setting a brisk pace and interrupting might frustrate the patient.
1. Which assessment findings validate that a patient with bipolar disorder is experiencing mania? Select all that apply. a. Pacing b. Agitation c. Drowsiness d. Delusional thoughts e. Psychomotor retardation
ANS: A, B, D Agitation, increased motor activity (pacing), and delusional thoughts may all accompany mania. The patient with mania would have an increased level of alertness rather than drowsiness. Psychomotor retardation would be expected with depression.
1. When a patient voices a delusion during a group session, how can the nurse effectively handle the situation? (Select all that apply.) a. Demonstrating empathy b. Presenting reality c. Exploring the delusional content d. Focusing on the underlying need expressed e. Asking the group what they think about the delusion.
ANS: A, B, D Responding to the voicing of a delusion during a group session is best handled by using empathy, focusing on the underlying need, and presenting reality. Delusional thinking does not respond to logic or criticism.
1. Which questions should the nurse ask to determine an individual's worldview? (Select all that apply.) a. "What is more important: the needs of an individual or the needs of a community?" b. "How would you describe an ideal relationship between individuals?" c. "How long have you lived at your present residence?" d. "Of what importance are possessions in your life?" e. "Do you speak any foreign languages?"
ANS: A, B, D The answers provide information about cultural values related to the importance of individuality, material possessions, relational connectedness, community needs versus individual needs, and interconnectedness between humans and nature. These will assist the nurse to determine whether the worldview of the individual is analytic, relational, community, or ecologic. Other follow-up questions would be needed to validate findings.
1. A patient asks, "What religions are considered monotheistic? " The nurse understands that religions are included? (Select all that apply.) a. Judaism b. Islam c. Buddhism d. Christianity e. Wicca
ANS: A, B, D The world's three largest monotheistic religions include Christianity, Islam, and Judaism. The remaining options are polytheistic religions.
1. During the impact stage of response to a violent crime, which nursing interventions would be appropriate for a victim? (Select all that apply.) a. Provide physical safety. b. Use empathetic responses. c. Distract the patient with humor. d. Provide clear, simple directions. e. Support expression of feelings.
ANS: A, B, D, E Because the individual experiences disorganization during the impact stage, the nurse must provide for safety and security via use of empathy, encourage expression of feelings, and provide simple clear directions. Humor might be helpful in the reorganization stage, not the impact stage.
3. Which assessment findings related to a 68-year-old patient should be identified as risk factors for late-onset alcohol abuse and dependence? (Select all that apply.) a. Chronic obstructive pulmonary disease b. Insomnia c. Male gender d. Boredom and loneliness e. Recent loss of spouse
ANS: A, B, D, E Insomnia or chronic medical illness might lead the individual to use alcohol to self-medicate. Loss of a spouse, boredom, and loneliness often result in alcohol use to escape emotional distress. Statistics show that more women than men develop late-onset problem drinking.
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.
2. Which interventions should a nurse include in the plan of care for a woman who has been physically abused by a partner for 10 years? (Select all that apply.) a. Be objective and nonthreatening. b. Help the victim to assess strengths. c. Make referrals contingent on leaving the abuser. d. Inform the woman that marital counseling is rarely effective. e. Help the victim recognize that the perpetrator's behavior is abusive.
ANS: A, B, E An objective, nonthreatening approach builds trust. Identifying the perpetrator's behavior as abusive is honest and supports the seriousness of the behavior. Helping the victim assess strengths will be necessary if the patient is to see herself as having sufficient resources to leave the abusive relationship. The distracters are nontherapeutic. Referrals should never be offered contingently. Marital counseling should be supported, if that is what the victim chooses. It might help reduce guilt feelings when the victim leaves the relationship.
2. Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? (Select all that apply.) a. "Lately I have had a lot of aches and pains and just haven't felt very well." b. "My appetite is better than usual, and I am sleeping about 9 hours a night." c. "People are in and out of my room all day and all night taking my things." d. "Don't ask me to eat. I can't because my stomach is upset all the time." e. "Life is more organized now that I don't live in my own home."
ANS: A, C, D Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The other options do not suggest symptoms of mental disorder.
2. Which situations are most likely to place severe, disabling stress on a family? (Select all that apply.) a. A parent needs long-term care after sustaining a severe brain injury. b. The youngest child in a family leaves for college in another state. c. A spouse is diagnosed with liver failure and needs a transplant. d. Parents of three children, age 9, 7, and 2 years, get a divorce. e. A parent retires after working at the same job for 28 years.
ANS: A, C, D Major illnesses place severe, potentially disabling stress on families. The distracters identify normal milestones in a family's development.
1. Which interventions should the nurse apply to the care plan of a patient requiring involuntary secluded? (Select all that apply.) a. Seclusion instituted when all less restrictive interventions are ineffective in managing behavior b. Written medical order to be obtained within 2 hours of implementation of intervention c. Patient to be debriefed when seclusion is discontinued d. Patient to be offered bathroom privileges hourly e. Patient evaluation every 15 minutes
ANS: A, C, D The correct interventions include debriefing, resorting to seclusion as a last resort, and evaluations should be done every 15 minutes. A medical order must be secured within 1 hour.
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.
2. What priority nursing assessments should be made early in the refeeding process for a patient with anorexia nervosa? (Select all that apply.) a. Vital signs b. Skin integrity c. Peripheral edema d. Lung and heart sounds e. Level of consciousness
ANS: A, C, D, E If refeeding results in too rapid weight gain, the cardiovascular system might be compromised, giving rise to symptoms such as pulse irregularities, peripheral edema, abnormal heart sounds, and moist lung sounds. Alterations in oxygenation and cardiac perfusion would produce changes in the level of consciousness. Changes in skin integrity would not be a priority.
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.
3. A newcomer to a community support meeting asks a nurse, "Why aren't people with mental illnesses treated at state institutions anymore?" What would be the nurse's accurate responses? (Select all that apply.) a. "Funding for treatment of mental illness now focuses on community treatment." b. "Psychiatric institutions are no longer accepted because of negative stories in the press." c. "There are less restrictive settings available now to care for individuals with mental illness." d. "Our nation has fewer people with mental illness; therefore, fewer hospital beds are needed." e. "Better drugs now make it possible for many persons with mental illness to live in their communities."
ANS: A, C, E Deinstitutionalization and changes in funding shifted care for persons with mental illness to the community rather than large institutions. Care provided in a community setting, closer to family and significant others, is preferable. Improvements in medications to treat serious mental illness made it possible for more patients to live in their home communities. Prevalence rates for serious mental illness have not decreased. Although the national perspectives on institutional care did become negative, that was not the reason many institutions closed.
2. Which intervention demonstrates that a nurse is functioning within the scope of psychotherapeutic management? (Select all that apply.) a. Structuring meaningful unit activities b. Administering electroconvulsive therapy c. Encouraging a patient to express feelings d. Interpreting the results of psychological testing e. Assessing a patient for medication side effects
ANS: A, C, E Milieu management, patient communication, and medication administration are all within the scope of nursing practice. Electroconvulsive therapy is a medical treatment and, therefore, should be administered by a physician. Psychological testing is interpreted by a psychologist.
2. A patient diagnosed with borderline personality disorder impulsively self-mutilates and has severe mood lability with explosive outbursts, poor interpersonal relations, and inability to sustain employment. Which referrals should the nurse consider for the patient? Select all that apply. a. Dialectic behavior therapy b. Alcoholics Anonymous c. Vocational rehabilitation d. Desensitization therapy e. Anger management
ANS: A, C, E Referral to dialectic behavior therapy will address self-mutilation and interpersonal relations and might address mood lability. Vocational counseling can help with employment problems. Assertiveness training and anger management will address the explosive outbursts. Desensitization therapy is used for patients with phobias. There is no evidence of alcohol abuse.
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.
A nurse can reduce the potential for experiencing negative feelings toward severely depressed patients by: Select all that apply. a. understanding the part neurotransmitters play in depression. b. disregarding empathic information originating in the patient. c. reducing focus on personal feelings toward the patient. d. establishing realistic expectations for patients and self. e. asking patients to explain why depression developed.
ANS: A, D Patients should understand that neurotransmitter dysfunction is a greater causative factor in depressive symptoms than patient choice. Keeping expectations realistic decreases feelings of helplessness and contributes to the maintenance of self-esteem. Self-assessment of feelings toward the patient is appropriate and necessary. Awareness of empathic messaging originating in the patient is essential because it is a clue to what the patient is experiencing. Most patients do not know why depression developed.
2. An individual is experiencing problems associated with speech and communication. Which cerebral structures are most likely to be involved in this deficit? (Select all that apply.) a. Frontal lobe b. Parietal lobe c. Occipital lobe d. Temporal lobe e. Basal ganglia
ANS: A, D The frontal and temporal lobes of the cerebrum play a key role in the reception of messages and speech. The occipital lobe is predominantly involved with vision. The basal ganglia influence integration of physical movement as well as some thoughts and emotions, whereas the parietal lobe is involved with sensory reception.
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.
3. Which principle is most useful and effective when interacting with a patient experiencing a manic episode? a. Encourage the patient to freely express feelings. b. Use a calm, matter-of-fact approach. c. Do not interrupt the patient. d. Frequently use silence.
ANS: B A calm, matter-of-fact approach minimizes the need for the patient to respond defensively and avoids power struggles. Using this approach, the nurse conveys both control of the situation and empathy. The other options are not principles related to therapeutic interactions with a patient experiencing a manic episode. The distracters allow for manipulation of the nurse and for the patient to control the interaction.
13. A parent said, "My child had mal ojo, so I did not give her the medicine for an ear infection." The nursing diagnosis of noncompliance was documented by the nurse who saw the child last. A culturally competent nurse should recognize that the situation occurred because of what factor? a. Lack of knowledge of therapeutic regimen b. Differences in perceptions of how illness occurs c. Evidence of unconscious hostility toward the child d. A misunderstanding about the communicability of microbes
ANS: B A parent who believes that his or her child's illness is the result of a spell cast on him or her will not understand the need for giving the child medication on a regular basis for several days. Diagnosing noncompliance will not help resolve the problem. Cultural negotiation and repatterning will be necessary. The other options do not present viable explanations.
7. A patient diagnosed with schizophrenia says, "I am a reincarnation of Jesus. I can raise the dead." Who is the most qualified person for the nurse to refer the patient to? a. Psychiatric nurse clinician b. Professional chaplain c. Clinical psychologist d. Community minister
ANS: B A professional chaplain holds a ministerial degree and has had a year of special study in ministering to individuals with spiritual concerns related to health problems. The other professionals have less knowledge and experience in dealing with the dual problems of mental illness and spiritual concerns.
12. A patient's serum lithium level is 1.8 mEq/L. Select the nurse's priority action. a. Restrict fluid intake. b. Assess for signs of toxicity. c. Encourage intake of high-potassium foods. d. Ensure that the patient is swallowing the capsules.
ANS: B A serum level of 1.8 mEq/L is higher than desirable. It suggests that the patient might be experiencing toxic effects. Clinical assessment should be conducted. A nurse should not rely entirely on laboratory tests but should make careful clinical assessments. None of the other options would be appropriate.
20. Which statement by an adult would lead a nurse to suspect deficits in mastery of the developmental task of infancy? a. "I wish I had more warm and close friendships." b. "I am afraid to let anyone really get to know me." c. "I am always right. Keep your opinion to yourself." d. "I am not ashamed of cheating at work."
ANS: B According to Erikson, the developmental task of infancy is the development of trust. The only statement clearly showing the lack of ability to trust others mentions being "afraid to let anyone really get to know me." The distracters suggest that the developmental task of infancy was successfully completed: rigidity rather than mistrust, and failure to resolve the crisis of initiative versus guilt.
13. To meet DSM-V criteria for bulimia nervosa, the patient's history must reveal episodes of binge eating and compensatory behaviors occurring at least how often? a. Once a week for 6 months b. Once weekly for 3 months c. Three times weekly for a year d. Four times weekly for 6 months
ANS: B Bulimia nervosa is characterized by three behaviors: recurrent episodes of binge eating, continuing inappropriate compensatory behaviors to avoid weight gain, and an evaluation of self that is significantly influenced by body weight and shape. These behaviors must be present an average of at least once per week, for a minimum of 3 months according to the DSM-V criteria.
11. A young adult has a realistic sense of self, a commitment to reasonable career goals, a satisfying intimate-partner relationship, and a circle of loyal friends. This person says, "I volunteer for important projects in my community." The nurse can draw which conclusion? a. There is lack of mastery of critical tasks associated with the stage of industry versus inferiority. b. Mastery of critical tasks associated with the stage of identity versus role diffusion is evident. c. Fear of criticism and affection affect mastery of critical tasks associated with intimacy. d. The person vacillates between dependence and independence.
ANS: B Adult behavior reflecting mastery of the critical tasks associated with the stage of identity versus role diffusion includes confident sense of self, emotional stability, commitment to career planning, sense of having a place in society, establishing a relationship with the opposite sex, fidelity to friends, and development of personal values. The behaviors given in the scenario are not indicators of any of the other options.
12. A young adult reports overwhelming guilt about minor social errors, feels self-pity, and says, "I stay on the sidelines of life so I can avoid the embarrassment of being noticed." The nurse can assess deficits in mastery of critical tasks associated with which developmental stage? a. Trust versus mistrust b. Industry versus inferiority c. Autonomy versus shame and doubt d. Generativity versus self-absorption
ANS: B Adult behaviors reflecting developmental problems associated with the stage of industry versus inferiority include excessive guilt and embarrassment, passivity, apathy, rumination and self-pity, assumption of the victim role, and underachievement of potential. The behaviors given in the scenario reflect the critical tasks of industry versus inferiority. Tasks of the other stages are entirely different.
13. An older retired executive reports, "I am unable to say 'no' when asked to help with community causes. These projects overtax my strength, but if I don't do them, who will?" The nurse can assess that this person is having difficulty with critical tasks related to which developmental stage? a. Trust versus mistrust b. Integrity versus despair c. Identity versus role diffusion d. Autonomy versus shame and doubt
ANS: B Adult behaviors reflecting problems associated with the developmental stage of integrity versus despair include inability to reduce activities, overtaxing strength, and feeling indispensable, or the opposite: feeling helpless, useless, or lonely; focusing on past mistakes; and inability to occupy oneself with satisfying activities. Tasks of the other stages are not described in the scenario.
14. A patient tells the nurse, "This medication makes me feel weird. I don't think I should take it anymore. Do you?" What is the nurse's best response? a. "I wonder why you think that." b. "Tell me how the medication makes you feel." c. "One must never stop taking medication." d. "You need to discuss this with your psychiatrist."
ANS: B As part of the psychopharmacology component of psychotherapeutic management, the responsibility of the nurse is to gather data about patients' responses to medication and to be alert for side and adverse effects of the medication. The other responses are tangential to the real issue.
1. A psychiatric nurse clinician on an inpatient unit plans to lead a special-problems group for withdrawn patients. Which information will be of most assistance as the nurse prepares for this assignment? a. Inpatient groups rarely have a lasting beneficial effect. b. Inpatient groups have short-term, goal-oriented sessions. c. Inpatient groups are helpful for patients with verbal skills. d. Inpatient groups facilitate insight into deeply rooted life issues.
ANS: B Because inpatient stays are so short and accountability is a major treatment issue, inpatient groups typically have short-term, goal-oriented sessions designed to teach patients more adaptive strategies for coping with life's problems. Beneficial effects are often lasting. Patients with or without verbal skills may be helped by selected types of groups. Insight-oriented therapy is conducted on an outpatient basis and usually occurs over the long term.
3. A kindergartener is disruptive to the class. This child is unable to sit for expected lengths of time, inattentive to the teacher, and aggressive toward others, bursting out talking while the teacher is talking. Other children shun this child. The nurse plans interventions designed to address which of the child's needs? a. Provide inpatient treatment for the child. b. Reduce loneliness and increase self-esteem. c. Improve language and communication skills. d. Promote individuation and integration of self-concept.
ANS: B Because of their disruptive behaviors, children with attention-deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These same behaviors lead peers to avoid the child with ADHD, who seems reckless and impulsive, and can rarely finish games, leaving the child with ADHD vulnerable to loneliness. The other options might or might not be relevant but are not the priority. The child does not need inpatient treatment at this time.
13. An 80-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the assessment, which initial action should be taken to maximize the effectiveness of the assessment? a. Move the interview to a darkened room to reduce stimulation. b. Ask if the patient can hear clearly as the nurse speaks. c. Ask the patient to rate the level of pain. d. Initiate a neurologic assessment.
ANS: B Before proceeding with any further assessment, the nurse should assess the patient's ability to hear questions. Impaired hearing could lead to inaccurate answers.
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.
17. A nurse is scheduled to interview a new patient, a Muslim college professor from the Middle East. Which action by the nurse would support cultural competence? a. Serve the patient a cold beverage at the beginning of the interview. b. Review Middle Eastern cultural values before the interview. c. Avoid offering to shake hands with the patient. d. Determine if a translator is available.
ANS: B Brushing up on Middle Eastern culture would be a sensitive action that might result in a lowering of barriers between the nurse and patient. It would not be necessary to serve beverages during the interview. A translator would probably not be needed if the patient is a college professor. Shaking hands with Middle Easterners is acceptable.
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.
15. The broadened scope of psychiatric nursing practice is attributable primarily to what factor? a. Increased use of psychotropic drugs b. Opening of community mental health centers c. Legislation that changed nurse practice acts across the country d. Recidivism of seriously mentally ill patients in public mental hospitals
ANS: B Community mental health centers were designed and organized to provide services in addition to inpatient hospitalization, thus giving nurses opportunities to practice in a variety of treatment settings (e.g., emergency rooms, partial hospitalization settings, outpatient care) and to have new roles, such as consultant, liaison, and case manager. Increased use of psychotropic drugs is not as important a factor as are community mental health centers. Legislation changing nurse practice acts broadened the scope of practice for nurse practitioners only by allowing prescriptive privileges. Recidivism is not a relevant factor.
3. A nurse counsels an 87-year-old veteran of World War II who tearfully shares memories of sights associated with Nazi concentration camps. Which term will be most familiar to this veteran? a) Shell shock b) Battle fatigue c) Soldier's heart d) PTSD
ANS: B Consequences of exposure to traumatic events associated with war have been addressed by different terms over generations. Battle fatigue was the term used in World War II. Soldier's heart was the term used after the Civil War. Shell shock was the term used in World War I. PTSD was the term used beginning with the Vietnam War.
3. Culture is defined as a group's shared demonstration of what characteristics? (Select all that apply.) a. Race and ethnicity b. Values c. Beliefs d. Patterned behavioral responses e. Norms
ANS: B Culture is the internal and external manifestation of a person's, group's, or community's learned and shared values, beliefs, and norms that are used to help individuals function in life and understand and interpret life occurrences. Patterned behavioral responses do not provide an adequate explanation of culture, because it's too narrow in scope. [BCD?]
16. A patient diagnosed with an acute was hospitalized for a week and is now being discharged to a halfway house, where care is managed by a community mental health nurse. Which inference applies to this community? a. Additional mental health services should be made available for the severely mentally ill. b. A seamless continuum of services is in place to serve persons with severe mental illness. c. Case management services should be expanded to care for acute as well as long-term system consumers. d. Care is effective for only a few selective psychiatric diagnoses.
ANS: B Data are sufficient to suggest that a seamless continuum of service is in place, because the individual is able to move between continuum treatment sources and is given the services of a case manager to coordinate care. Data provided are insufficient to warrant any of the other assessments.
18. A mother and her two children are in the emergency department for treatment of trauma experienced when the woman's husband physically abused her and the children. What is the nurse's priority intervention? a. Conduct a detail medical history on both mother and children. b. Focus on physical safety and emotional security of mother and children. c. Discuss the mother's legal rights in this situation. d. Discuss the legal obligation to notify the Child Protection Services.
ANS: B During the impact stage, the victim is acutely aware of the danger she has just escaped. Believing that the next beating could be fatal might provide incentive to take constructive action. The nurse can assist the victim to begin to consider a plan for escape when the next beating seems imminent and can provide information about resources. The remaining options are appropriately addressed after future safety is discussed.
5. An older adult patient is severely suicidal and the patient's physical condition is declining. When it is apparent that traditional interventions are ineffective, the nurse should prepare for which intervention? a. Insertion of a feeding tube b. Electroconvulsive therapy (ECT) c. Behavior modification d. Bright-light therapy
ANS: B ECT is the treatment of choice for severe depression in older adults when a rapid response is necessary. Bright-light therapy and behavior modification will take too long. The patient does not have assessment findings that indicate enteral feeding is needed.
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.
17. A patient at the crisis intervention clinic states, "When I got up this morning, I realized I could not go on any longer." What is the nurse's best response to facilitate analyzing the problem and making a nursing diagnosis? a. "How long have you been feeling this way?" b. "What is different about your feelings today?" c. "We are here to help you. I'm glad you decided to come to the center." d. "You said you felt like you could not go on. Tell me more about that."
ANS: B Encouraging comparison is a useful technique when the nurse wishes to analyze the problem and draw conclusions to facilitate establishing a nursing diagnosis. None of the other options would be as effective in encouraging the patient to analyze feelings.
15. Excitotoxicity in persons diagnosed with TBIs is associated primarily with which neurotransmitter? a) Norepinephrine b) Glutamate c) Dopamine d) Serotonin
ANS: B Excitotoxicity is associated with overfiring of neurons secondary to activation of glutamate. The remaining options are not associated with this reaction.
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.
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.
18. An African-American patient tells a nurse with a European-American worldview, "There's no sense talking. You wouldn't understand because you live in a white world." What is the nurse's best response In order to build the nurse-patient relation? a. "Nurses are educated to care for people from all cultures. It is a required component of nursing education." b. "It would be helpful if you described an example of something you think I would not understand." c. "Your mental illness is causing you to view me with prejudice. We are all here to help you." d. "Yes, I do understand. Everyone goes through the same experiences."
ANS: B Having the patient speak in specifics rather than globally will help the nurse understand the patient's perspective. This approach will help the nurse establish rapport with the patient. False reassurances will not facilitate communication with the patient.
11. A nurse manages a program providing day treatment services to combat veterans diagnosed with PTSD. During breaks between activities, which type of music would be most appropriate? a) Rap b) Jazz c) Rock d) Hip-Hop
ANS: B Hypervigilance is a common symptom of PTSD and leads to difficulty with relaxation. Music can soothe if it is not overpowering. Jazz is mellow and would not contribute to hyperarousal. Rap, rock, and hip-hop would be overstimulating.
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.
1. For a victim of spousal abuse, a deterrent to leaving the abusive situation are the events that occur in which stage? a. Tension building b. Honeymoon c. Processing d. Battering
ANS: B In the honeymoon stage the perpetrator is apologetic and kind, attempting to undo the harm of the battering incident. The perpetrator promises never to repeat the battering. The events occurring in the other options would not be deterrents to leaving. The processing stage is not an actual stage in the cycle.
A person loves being the center of attention. Recently this person sustained a paper cut on a finger and called an ambulance. The patient says, "I can't believe my supervisor denied my sick leave request." This individual most clearly displays traits of: a. dependent personality disorder. b. histrionic personality disorder. c. antisocial personality disorder. d. borderline personality disorder
ANS: B Individuals with histrionic personality disorder dramatize all events and draw attention to themselves. Patients might use somatic complaints to avoid responsibility and support dependency
A nurse caring for a person diagnosed with schizoid personality disorder expects which assessment findings? a. Impulsive, restless, socially aggressive behavior b. Few interactions with others; little verbalization c. Magical thinking; suspicious, odd behavior d. Distrustful, cold, often angry behaviors
ANS: B Individuals with schizoid personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The distractors characteristically apply to antisocial personality disorder, schizotypal personality disorder, and paranoid personality disorder
13. A nurse begins working in a clinic housed in a homeless shelter. The nurse asks the clinic director, "What topic should I review to improve my effectiveness as I begin my new job?" Which topic should the clinic director suggest? a. Care of school-age children b. Psychiatric assessment c. Communicable disease prevention strategies d. Sexually transmitted disease signs and symptoms
ANS: B It is estimated that significant numbers of the homeless population have a serious mental illness and/or suffer from substance abuse or dependence. Although the other conditions may exist, the numbers are not as significant.
25. A patient diagnosed with paranoid schizophrenia believes that evil spirits are being stirred by a local minister and verbally threatens to bomb a local church. Considering the rights of this patient, what is the initial nursing responsibility? a. Obtaining the patient's permission to release this information to the police b. Recognizing and acting upon the duty to warn and protect c. Protecting the patient's right to confidentiality d. Reviewing the criteria associated with malpractice so as to avoid committing this tort
ANS: B It is the health care professional's duty to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional. It is not considered a violation of confidentiality or an example of malpractice and patient consent is not required.
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.
15. A nurse cares for a Chinese-American patient diagnosed with major depression. After the nurse reviews the therapeutic regimen with the patient, which intervention should be implemented next? a. Verify understanding by asking the patient to restate the information. b. Ask if the patient is willing to follow directions for medications. c. Reinforce cultural norms about eating hot and cold foods. d. Provide the information in written form to the patient.
ANS: B Many Asians and Asian-Americans believe that questioning an authority figure (nurse) would be disrespectful, so they do not ask for clarification when they do not understand directions for their treatment. Individuals of this culture are usually willing to comply once they understand. Written information may be provided later. Although hot and cold foods might be used by Asian-Americans, there is no evidence that this patient is interested in this therapy.
14. A nurse cares for a man diagnosed with pedophilia. Medroxyprogesterone acetate was prescribed. One month later, which statement by the patient indicates that the medication is having a therapeutic effect? a. "I feel a lot less depressed since taking this drug." b. "My sexual desire has practically disappeared." c. "I can sustain an erection longer than before." d. "There's no pain during intercourse now."
ANS: B Medroxyprogesterone acetate is an antiandrogen. When testosterone is reduced, sexual desire is decreased. The statement that sexual desire has "practically disappeared" suggests that the medication is having the desired effect. The distracters are unrelated to the desired effect of this drug.
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. When considering environmental aspects of milieu management, which intervention has the highest priority for a client admitted after a failed suicide attempt? a. Sending the client's new medication prescriptions to the pharmacy b. Assigning a staff member to one-on-one observation of the client c. Orienting the client to the milieu's public and private spaces d. Having all potentially dangerous items removed from the client's belongings
ANS: B Milieu management provides a proactive approach to care. Safety overrides all other dimensions of the milieu. Initiation of suicide precautions are the priority for this client. All the remaining options are appropriate but none protect the client from the risk of another attempt to self-harm as effectively as one-on-one observation as part of suicide precautions.
3. A nurse plans a staff education program for employees of a senior living community. Which topic has priority when considering client safety? a. Late-onset schizophrenia b. Depression and suicide c. Dementia d. Delirium
ANS: B Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease
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.
8. A patient of Hispanic descent is hospitalized with depression. Considering the traditional cultural world view, which intervention is most applicable to care planning for this patient? a. The nurse should confer with the family's oldest woman, who will serve as the primary decision maker. b. With the patient's permission, the nurse should consult with family and religious advisors to plan care. c. The plan of care should incorporate use of meditation and contemplation techniques. d. Acknowledge that Western medical treatment will be readily accepted by the patient.
ANS: B Patients of Hispanic cultures often have relational worldviews. Individuals who have a relational worldview usually desire the involvement of family, religious advisors, and even friends during health care visits and the planning of interventions. The patient's consent is required for this involvement. The other options reflect alternative worldviews.
18. A senator develops a sexual relationship with a 20-year-old receptionist. Which adjective most likely applies to this relationship? a. Harmonious b. Consensual c. Coercive d. Illegal
ANS: C Relationships between powerful and less powerful persons usually have a coercive element. They are not illegal unless the less powerful person is a minor. The relationship may be harmonious and consensual in the minds of the involved parties.
8. A pedophile receiving treatment tells the nurse, "I feel so guilty and shameful over molesting a child. My family will be so disgusted with me. I could save them from embarrassment if I were gone." What is the nurse's priority action? a. Set limits on the patient's disclosures. b. Further assess the patient's suicidality. c. Administer a PRN medication for anxiety. d. Explore the patient's feelings of guilt and shame.
ANS: B Patients who describe guilt, shame, and the idea that others would be better off without them are suicide risks. The nurse should further assess the patient's comments, document, report the data, and consider the need for suicide precautions. The other options do not fully consider the primary issue of patient safety.
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.
1. Which statement accurately applies to personality disorders? a. One aspect of personality is usually involved. b. Personality traits are dysfunctional and inflexible. c. Patients have subjective distress, but not impaired functioning. d. Symptoms have a short duration and are responsive to treatment.
ANS: B Patients with personality disorders suffer lifelong inflexible and dysfunctional patterns of relating and behaving. The patient experiences subjective distress, usually based on others' reactions to him or her, and functioning is impaired. More than one aspect of personality is involved: personality disorders are described as pervasive. Behaviors are complex and difficult to manage.
15. On the admission papers, a patient checked the box labeled "No religious affiliation." What meaning can the nurse draw from this information? a. The patient is not religious. b. The patient is among a growing group. c. The patient has conventional religious values. d. The patient is probably experiencing spiritual distress.
ANS: B People hold strong opinions about spirituality and religion, but a significant number—39%—of young Americans aged 18 to 29 are religiously unaffiliated, four times as many as a generation ago. The distracters offer misinformation and misinterpretation about the meaning of "No religious affiliation."
1. When a nurse assesses a family, which family task has the highest priority to facilitate healthy family functioning? a. Allocation of family resources b. Physical maintenance and safety c. Maintenance of order and authority d. Reproduction of new family members
ANS: B Physical and safety needs are given greater importance in Maslow hierarchy of needs than other needs since it addresses the basic safety needs.
4. A resident in a senior community has lost weight, feels depressed, and has lost interest in former social activities. The nurse asks, "When you last saw your doctor, did you share these problems?" The resident replies, "Yes, but the doctor said I shouldn't expect to feel good every day." Which barrier to mental health care is evident? a. Legislative failures to provide services for older adults b. The physician's inadequate mental health assessment c. The resident's inadequate description of symptoms d. Economic obstacles to adequate programming
ANS: B Primary-care physicians are often hurried and have little time to spend with patients. In addition, they are more attuned to and more comfortable treating physical problems than mental disorders. They often miss depressive symptoms in older adults, thus creating a barrier to effective treatment. The patient's description of symptoms was adequate. Economic and legislative policies are not discussed in the scenario.
16. Which patient would benefit most from a group that focuses on reality orientation? a. Adolescent with mixed drug and alcohol abuse b. Adult with undifferentiated schizophrenia c. Older adult with depression d. Young adult in crisis
ANS: B Reality orientation groups are helpful for patients who are confused and unable to perceive and interpret reality accurately. The patient with undifferentiated schizophrenia is the choice of patients for the reality group, because misperception of reality and poor reality testing are usually part of the patient's clinical picture. None of the other options focus on this component of therapy.
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.
12. Reducing aggressive outbursts on a unit for older adults with mental disorders can be best achieved by implementing which intervention? a. Administering antipsychotic medication when signs of aggression are first noted b. Redirecting a client who demonstrates verbal aggression c. Limiting diversional activities to manage stimuli d. Restricting the clients' personal space to help facilitate visual observation of the group.
ANS: B Redirection and diversion are effective techniques to prevent and/or manage aggressive outbursts. Liberal use of medication will result in oversedation. Diversional activity can provide constructive outlets, so it should not be restricted. Control over one's personal space reduces aggression. Real or imagined threats to personal space might incite aggression.
14. A nurse presents a psychoeducational program to patients with bipolar disorder and their families. Information about signs of impending relapse of mania should include: a. diarrhea, thirst, and gross tremor. b. sleep disturbances and racing thoughts. c. decreased libido, anhedonia, and hypersomnia. d. delusional thinking, excessive guilt, and passivity.
ANS: B Relapse symptoms are congruent with early symptoms of a manic episode. They include sleeping less, experiencing racing thoughts, and having boundless energy. Diarrhea, thirst, and tremor relate to lithium side effects. Libido increases. Delusional thinking may occur in an exacerbation of the illness but not usually before relapse.
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.
6. A nurse planning care for a patient diagnosed with bulimia nervosa should recommend the use of what for therapy? a. Psychodynamic group therapy. b. Cognitive-behavioral therapy. c. Pharmacotherapy. d. Psychodrama.
ANS: B Research findings indicate that cognitive-behavioral therapy is effective in the treatment of both anorexia nervosa and bulimia nervosa. There is no evidence to suggest that the other options are as useful.
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.
12. A nurse is engaged in psychoeducational activities with a hospitalized teenage patient diagnosed with bulimia nervosa. What response should the nurse provide when a patient asks, "What should I do when I feel the need to vomit?" a. "Do vigorous aerobic exercise until the urge goes away." b. "Seek out a staff member to talk about your feelings." c. "Call your parents on the phone to show you care." d. "Allow yourself to vomit, but avoid purging."
ANS: B Resistance to the urge to vomit or purge can be strengthened by reporting it to a nurse and talking about the feelings that the individual experienced before the urge and the feelings being experienced presently. Once feelings are identified, the patient can begin to work on alternate coping strategies. The other options are not helpful.
16. A patient was restrained after assaulting a staff member. Which nursing measure has priority? a. Assess the patient for comfort needs every 15 minutes. b. Maintain constant supervision of the patient. c. Administer a sedating medication after applying the restraints. d. Distract the patient at frequent intervals while restraints are in use.
ANS: B Restrained patients must be constantly observed, with documentation of physical safety and comfort interventions occurring at 15-minute intervals. Medication may be administered, but this is not the priority action. Distraction is not an effective technique to use when a patient is in restraints, because minimal stimulation is preferred.
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.
21. A patient diagnosed with long-standing bipolar disorder comes to the mental health center. The patient says, "I lost my job and home. Now, I eat in soup kitchens and sleep at a shelter. I am so depressed that I thought about jumping from a railroad bridge into a river." Which factor has priority for the nurse who determines the appropriate level of care? a. Long-standing bipolar disorder b. Risk for suicide c. Homelessness d. Lack of income
ANS: B Risk assessment shows the patient to have suicidal thoughts, and a plan for the suicide that is highly lethal, executable, and with low potential for rescue. The other factors do not have as great an effect on the determination of the level of services needed since they are less related to acute safety.
10. A nurse wants to provide opportunities for a patient to try out new, more assertive behaviors. Which technique should the nurse use? a. Clarifying b. Role-playing c. Giving feedback d. Encouraging evaluation
ANS: B Role-playing permits the patient to practice new behaviors in a safe setting and to develop comfort with the use of the new behaviors. The nurse plays a particular role and provides coaching and feedback. The other techniques given as options do not encourage the patient to practice new behaviors.
16. Which scenario best illustrates scapegoating within a family? a. Messages of aggression are sent by the identified patient to selected family members. b. Family members project problems of the family onto one particular family member. c. The identified patient threatens separation to induce feelings of isolation and despair. d. Family members give the identified patient nonverbal messages that conflict with verbal messages.
ANS: B Scapegoating projects blame for family problems onto a member who is less powerful. The purpose of this projection is to distract from issues or dysfunctional behaviors in the family members. None of the other options deals with blames and power.
19. Which assessment findings would prompt a nurse to suspect that a 15-year-old patient may be a victim of serial ritual abuse? a. Lying in a fetal position; echolalia; body rocking b. Multiple scars and burns; missing teeth; fear of being examined c. Scarred index finger; tooth enamel erosion; sores around mouth d. Acting-out behaviors; verbal aggression; arrested for grand larceny
ANS: B Scarring, burns, and missing teeth fit the picture of ritual abuse. The fear of examination relates to having to remove clothes in preparation for torture. The distracters are more consistent with schizophrenia, bulimia nervosa, and antisocial personality disorder.
9. A patient says, "I wish I could express my depressed feelings rather than keeping them inside." The nurse should schedule the patient to attend which type of group? a. Social skills b. Special problems c. Reality orientation d. Relapse prevention
ANS: B Scheduling the patient for group sessions with others with depression would allow the patient to address this need in a supportive, understanding environment. The patient does not need reality orientation or social skills and has not expressed a need for relapse prevention information.
Select the best outcome for a patient with schizotypal personality disorder. The patient will: a. adhere willingly to program norms. b. introduce himself or herself to a stranger in a social situation. c. report decreased incidence of impulses to self-mutilate. d. demonstrate fewer attempts at splitting or manipulating staff.
ANS: B Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal personality disorder usually have no issues with adherence to unit norms, nor are they self-mutilating or manipulative.
A patient diagnosed with seasonal affective disorder asks, "Will I ever feel better?" Based on understanding of this psychopathology, the nurse's best response is: a. "Your depressed mood will probably spontaneously improve in 6 months to a year." b. "People with seasonal affective disorder usually feel better in spring and summer, when there are longer periods of light." c. "It's important to engage in community activities to improve your depressed mood. Activity stimulates important brain chemicals." d. "Most people with seasonal affective disorder feel better during the fall and winter seasons as they experience the pleasure of the holidays."
ANS: B Seasonal affective disorder is a depression occurring in conjunction with a seasonal change, most often beginning in fall and winter and remitting in spring in the Northern Hemisphere. The correct answer is the only option that reflects the information regarding the seasonal nature of the disorder.
6. Which finding necessitates immediate nursing action for a child being treated for depression with a selective serotonin reuptake inhibitor (SSRI)? a. A weight gain of 10 lb in 4 weeks b. Repeatedly hitting a younger sibling c. Frequently reports being tired and just wanting to sleep d. Has fallen three times as a result of "being dizzy"
ANS: B Selective serotonin reuptake inhibitors (SSRIs) are frequently used in children and adolescents. Some aggressive and out of control behaviors, and even suicidality have been linked to these serotonin-enhancing drugs. The other drug side effects are associated with tricyclic antidepressants.
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.
9. A caregiver says, "Both of my parents have dementia. I find it so difficult to care for them because of their disabilities. I get depressed and hopeless thinking about it. Can you give me any suggestions for coping?" Before making any suggestions, the nurse should implement what assessment? a. The parents' stage of dementia b. The caregiver's religious ideology c. Whether or not the parents' medications are helping d. If financial resources are sufficient to provide a health care aide
ANS: B Serious illness of loved ones often presents difficult dilemmas and problems in adjustment for caregivers. It is known that religious activities are important coping mechanisms for many African-American caregivers of older adults. The correct answer is the only option directly concerned with caretaker coping. The foci of the other options are on the parents.
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.
4. Which statement made by a nurse demonstrates an understanding of the issue affecting the delivery of care to the mentally ill that motivated passage of the Community Mental Health Centers Act in 1963? a. "Involuntary hospitalized occurs only if a client demonstrated violent behavior." b. "We attempt to address the issues that occur when a client is geographically isolated from family and community." c. "Legally a voluntarily admitted client can demand to be discharged before receiving adequate treatment." d. "Mental ill clients must give informed consent before being used as subjects in pharmacologic research."
ANS: B State hospitals were often located a great distance from the patients' homes, making family visits difficult during hospitalization. The Community Mental Health Centers Act in 1963 served as the impetus for deinstitutionalization, allowing patients and families to receive care close to home. Admission only for behavior that endangers self or others is more consistent with current admission criteria. Early discharge rarely occurred before the community mental health movement. Unethical pharmacologic research was not a major issue leading to community mental health legislation.
3. A patient diagnosed with schizophrenia, paranoid type, frequently gets up, and walks away during interactions with a nurse. How can the nurse best increase the patient's comfort level and so encourage communication? a. Arranging the chairs side by side, about 2 feet apart b. Sitting at eye level across the table from the patient c. Standing a few feet away from where the patient sits d. Talking in the patient's room with the door closed
ANS: B Suspicious patients require increased personal space. Sitting across the table provides that space. Being at the same eye level fosters communication. Side-by-side placement of chairs might not give the suspicious patient the ability to watch the nurse closely enough for comfort. Being in a closed room might be threatening to the patient.
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.
2. A nurse cares for a first-generation American whose family emigrated from Germany one generation ago. This patient would probably have which worldview about the source of knowledge? a. Knowledge is acquired through use of affective or feeling senses. b. Knowledge is acquired according to proof of existence. c. Knowledge develops by striving for transcendence of the mind and body. d. Knowledge evolves from an individual's relationship with a supreme being.
ANS: B The European-American perspective of acquiring knowledge evolves through acquiring proof that something exists using the personal senses. The distracters describe the beliefs of other cultural groups.
1. Considering the M'Naghten Rule, what information is most important for the nurse to document when caring for a patient who will soon be tried on murder charges? a. The patient's participation in treatment planning b. The patient's comments about commission of the crime c. Examples of behaviors that support psychiatric diagnoses d. The patient's perceptions of the need for hospitalization and treatment
ANS: B The M'Naghten Rule states that to be held legally accountable for his or her actions, a person with mental illness must be able to understand the nature and implications of the crime. Although each of the options refers to data that should be documented, the patient's comments about the crime would be of most importance to the trial.
12. Which individual should the nurse assess as having the highest risk for homelessness? a. An older adult woman with mild dementia who lives alone in an apartment b. An adult with serious mental illness and no family c. An adolescent with an eating disorder d. A married person with alcoholism
ANS: B The adult has both a serious mental illness and a potentially weak support system. Both are risk factors for homelessness. The other individuals have psychiatric disorders but have better established support systems.
19. A Korean-American patient showed rare eye contact. This nursing diagnosis was formulated: Chronic low self-esteem related to shame and guilt as evidenced by lack of eye contact. Interventions were sought to improve the patient's self-esteem, but after 3 weeks the patient's eye contact was unchanged. What is the accurate analysis of this scenario? a. The patient's poor eye contact indicated anger and hostility that did not resolve. b. The nurse should have assessed the patient's culture before formulating this diagnosis and plan. c. Resolution of shame and guilt cannot be expected to occur in 3 weeks. The nurse should allow more time. d. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact.
ANS: B The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected and valued. Korean-Americans often prefer not to engage in direct eye contact.
Which statement by a depressed patient confirms the need for suicide precautions? a. "God has helped see me through this illness." b. "I don't understand why God has abandoned me." c. "I believe God will lift the dark cloud of depression." d. "I am comforted when I read the Twenty-Third Psalm."
ANS: B The answer reveals isolation even from God. When such profound isolation is experienced, the person might consider suicide as an option to relieve the emotional pain of illness. The other options relate to a sense of hope.
16. A child shares with the school nurse about painful verbal bullying by an aggressive classmate. What should be the nurse's initial action? a. Give notice to the chief administrator at the school regarding the events. b. Support the victimized child to share feelings about the experience. c. Encourage the victimized child to ignore the bullying behavior. d. Discuss the events with the aggressive classmate.
ANS: B The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the child's complaints and validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.
17. A community mental health nurse assessing a person with a psychiatric disorder, should refer this person to services based on which basic concept? a. Focus on interventions is on the least costly initially. b. Initial interventions are the least restrictive. c. Initial interventions offer a form of psychoeducation. d. Rapid symptom stabilization is the primary goal.
ANS: B The concept of least restrictive treatment environment preserves individual rights to freedom. Many patients are healthy enough to receive community-based treatment. Hospitalization is reserved for short periods when patients are assessed as being a danger to self or others. Cost is a consideration but is of lesser concern than safety. All facets of the continuum should offer psychoeducation as needed by patients and families. Some aspects of the care continuum are more concerned with a patient's need for symptom stabilization than others (e.g., hospitals versus psychiatric rehabilitation programs). The outcome of symptom stabilization is not a need for some patients, so it is not a correct answer.
13. A patient diagnosed with schizophrenia reports hearing demon voices coming through the television. Which statement by the nurse providing spiritual care would be most comforting to the patient? a. "Rest assured that God will fill your heart with peace." b. "I am concerned about your spiritual distress." c. "God will hold you in the palm of His hand." d. "God knows your every thought."
ANS: B The correct answer shows compassion and caring on the part of the nurse and contributes to trust building. The nurse has offered concerns, which reassures the individual that he or she will not be abandoned. The other options each include abstract concepts that are difficult for someone who thinks concretely to interpret correctly. They might even be frightening to patients who think concretely
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.
When communicating with a withdrawn, depressed patient who speaks slowly and in monosyllables, the nurse should: a. be as cheerful as possible. b. use simple, direct sentences. c. use silence while assisting the patient. d. frequently encourage the patient to elaborate.
ANS: B The depressed patient is often preoccupied with ruminations and unable to focus on what is being said. Directions should be simple and direct. Cheerfulness emphasizes the emotional distance between the nurse and a depressed patient. Being largely silent suggests disinterest in the patient. Carrying on a stream of "chatter" reduces the patient's opportunity to communicate.
3. A 15-year-old patient is hospitalized after a suicide attempt. The adolescent lives with his mother, stepfather, and several siblings. When performing a family assessment, the nurse must first focus on securing what information? a. How the family expresses and manages emotion. b. The names and relationships of the patient's family members. c. The communication patterns between the patient and parents. d. The meaning the patient's suicide attempt has for family members.
ANS: B The names and relationships of the patient's family members constitute the most fundamental information and should be obtained first. Without this, the nurse cannot fully process the other responses.
7. When assessing a patient's social skills, which remark would serve best in seeking clarification? a. "It sounds as if you need to develop some assertiveness skills." b. "Describe an example of a time when you felt uncomfortable in a social situation." c. "It is not easy to be assertive. We can role-play some situations to give you practice." d. "What do you plan to do the next time you find yourself in an uncomfortable social situation?"
ANS: B The nurse is seeking clarification, a therapeutic technique that is a useful assessment tool. Mention of assertiveness skill development indicates that the assessment has been made. Asking for the patient's plan would occur during problem-solving rather than 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 in a detoxification unit asks, "What good will it do to go to Alcoholics Anonymous and talk to other people with the same problem?" The nurse's best response would be to explain that self-help groups such as AA provide opportunities for what beneficial experience? a. Newly discharged alcoholics can learn about the disease of alcoholism. b. People with common problems share their experiences with alcoholism and recovery. c. Patients with alcoholism receive insight-oriented treatment about the etiology of their disease. d. Professional counselors provide guidance to individuals recovering from alcoholism.
ANS: B The patient needs basic information about the purpose of a self-help group. The basis of self-help groups is sharing by individuals with similar problems. Self-help is based on the belief that an individual with a problem can be truly understood and helped only by others who have the same problem. The other options fail to address this or provide incorrect information.
7. A man experiencing premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner. Can you help me?" What is the nurse's best response? a. "Sex therapy is not my specialty, but I will try to help." b. "I can refer you to a practitioner with experience regarding this problem." c. "Have you asked your health care provider for prescription medication?" d. "There are several techniques described in this pamphlet that might be helpful."
ANS: B The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurse's role.
9. The implementation of which unit policy directed at milieu balance would reflect a need for reconsideration on the part of the treatment team? a. All clients will receive verbal and written information explaining unit rules. b. Unit clients will engage in all unit activities to assure interaction with both staff and other clients. c. All clients will be uniformly expected to present themselves in a nonviolent manner to both staff and other clients. d. At times of unit stress, client will return to their rooms.
ANS: B The situation described suggests a milieu in which patients have no time for planned therapeutic encounters with staff; hence, it is a milieu lacking balance. The remaining options address unit norms, limit setting, and environmental modifications that are reasonable and will contribute to a therapeutic milieu.
8. A patient's plan of care includes this nursing diagnosis: Impaired verbal communication related to lack of assertiveness skills. To include the patient in prioritizing this problem, what statement should the nurse make to the patient? a. "Who are the people with whom you are most passive?" b. "How important is it for you to become more assertive?" c. "Let's look at how we can address this problem together." d. "Are you interested in attending the assertiveness class?"
ANS: B The technique of encouraging evaluation is useful to the nurse who is attempting to interpret meaning and importance. It seeks the patient's view of the situation and provides a basis for setting priorities. The other options are not concerned with priority.
8. The nurse assesses a patient diagnosed with Parkinson disease. When will tremors be most pronounced? a. When sleeping b. When sitting quietly c. When focusing intently d. When reaching for something
ANS: B The tremor of Parkinson disease, a disease that affects the extrapyramidal system, is most pronounced when the patient is at rest. In Parkinson disease, tremor is absent during sleep and diminished when concentrating or with intentional movement.
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.
5. A woman accompanied by her domestic partner is being assessed for reports of neck pain. When the nurse notes a bald spot on the client's scalp, the woman explains that she caught her hair in a door, which pulled it out and caused her neck injury. What is the nurse's best action to facilitate the assessment? a. Ask the client if she prefers her partner to stay during the examination. b. Require the partner to stay in the waiting room when the woman is examined. c. Call hospital security to have them stand by to prevent violence. d. Report the situation to local law enforcement authorities.
ANS: B The victim's explanation of being injured does not sound plausible. The nurse should suspect partner abuse. Regarding the other options, the victim and perpetrator must be separated to permit the victim the privacy to discuss what has really happened to her. It is unlikely that the perpetrator will act out when he can be observed by others. It is too early to involve the local police.
1. When interacting with patients, it is important for the nurse to recognize that defense mechanisms are used for what outcome? a. Keep id impulses from gaining control. b. Protect the ego from excessive anxiety. c. Access unconscious feelings and memories. d. Prevent conflict among the id, ego, and superego.
ANS: B Theorists widely accept the Freudian concept that ego defense mechanisms operate unconsciously to lower anxiety. The function of defense mechanisms is limited to anxiety control, so the other options are incorrect.
10. A patient has taken lithium (Lithane) 600 mg three times daily for 1 week. A laboratory result in which range shows that the desired serum lithium level was achieved? a. 0.2 to 0.6 mEq/L b. 0.6 to 1.2 mEq/L c. 1.2 to 2 mEq/L d. 2 to 2.6 mEq/L
ANS: B Therapeutic serum lithium levels are 0.6 to 1.2 mEq/L. The other options are either too low or too high. Serum levels above 1.5 mEq/L can cause symptoms of toxicity.
6. The nurse prepares to take vital signs for a patient experiencing mania. What is the nurse's best intervention when the patient's talking interferes with the assessment? a. Use a voice volume louder than the patient's to say, "Stop talking now." b. Interrupt by saying, "It's time to take your vital signs now." c. Delay taking the vital signs until the patient is quieter. d. Wait tolerantly for the patient to finish talking.
ANS: B There are times when the nurse must simply, calmly, and firmly interrupt a manic patient. Waiting is counterproductive. Yelling at the patient and delaying necessary assessments are inappropriate.
5. Which statement made by a nurse demonstrates an understanding about why completing a spiritual assessment is important? a. "Research clearly demonstrates that spiritual interventions by nurses are a cost-effective practice." b. "Accrediting organizations regard spiritual care as a patient right." c. "Spirituality is better addressed by nurses than by clergy." d. "Prayer consistently improves mental health outcomes."
ANS: B There is a lack of agreement as to whether or not spiritual care should be a legitimate concern of nurses, despite a large body of research evidence citing its advantages to patients. Among the major deterrents to including spiritual care is the concern that already overburdened nurses will not find time to perform the assessment. It should be noted, however, that when an accrediting body considers a facet of care to be a right of patients, it will look for evidence of attention to that right. A spiritual assessment documented in the medical record provides such evidence. The other options are of lesser importance when weighed against the standards set by an accrediting agency.
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.
23. What explanation regarding the unit milieu would be most important for the nurse to give to a newly admitted patient? a. "Your behavior will be carefully monitored during your hospital stay." b. "Unit activities will help you cope with immediate needs and stressors." c. "You will be given enough medication to bring your symptoms under control." d. "I will be gathering information about you to plan your care and your discharge."
ANS: B This choice best reflects the purpose of milieu management in psychotherapeutic management as demonstrated through unit activities. Stating that behavior will be monitored creates suspicion. Discussing medication administration is a psychopharmacology issue and is not pertinent to unit milieu. Stating that assessment will take place is not directly related to milieu.
15. A patient scheduled to attend various group sessions reports, "I'm really mad about having to attend all those groups. No one else spends all day in a circle in a little room." What is the nurse's best response to the patient's concerns? a. "Why are you upset?" b. "I can hear that you are upset. Let's talk about it." c. "Just go along with the plan, even if you do not agree." d. "The groups are carefully planned by staff to benefit patients."
ANS: B This remark exemplifies therapeutic listening. It acknowledges the patient's negative feelings and the nurse's willingness to listen as the patient offers his concerns. It implies a willingness to assist with problem-solving. "Why" questions are not therapeutic, because they often elicit rationalization. Justification is defensive and closes off communication.
18. A newly admitted patient asks the nurse, "Can you hear those people laughing at me? They are making fun of me." What is the nurse's best response? a. "You are mistaken. No one is laughing at you." b. "I know the sound of laughter is real to you, but I don't hear it." c. "Your mind is playing tricks on you, making you think you hear laughter." d. "When people are mentally ill, they often experience things that others cannot relate to."
ANS: B This reply acknowledges the patient's perceptions and gently casts doubt on the reality of the patient's conclusions through the use of an "I" statement. It is not argumentative or accusative as are the distracters.
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.
17. A patient diagnosed with an eating disorder refuses to be weighed and says, "I just drank a big glass of water." What is the nurse's best response to the patient's comment? a. "Call me after you have emptied your bladder." b. "Being weighed today is not negotiable." c. "I will weigh you tomorrow." d. "You know the rules."
ANS: B This response is matter-of-fact and reinforces the established limits. The distracters allow the patient to manipulate the nurse, are overly controlling, or use bargaining.
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.
22. An individual diagnosed with alcohol dependence will begin motivational enhancement therapy. The nurse will explain this therapy to significant others as a way of achieving what patient goal? a. Altering the patient's irrational thoughts b. Enhancing the patient's willingness to change behavior c. Managing the patient's anxiety through satisfying interpersonal interactions d. Mastering critical developmental tasks the patient did not attained earlier in life
ANS: B This variation of cognitive-behavioral therapy uses motivational interviewing to bolster the patient's readiness and willingness to change habits related to the addiction. Motivational enhancement therapy is a nonconfrontational approach that uses empathy and promotes self-efficacy. The other options are consistent with interpersonal therapy, cognitive therapy, and the use of Erikson model.
A depressed patient has just responded to the nurse in an overtly angry manner. Select the nurse's best response. a. "I seem to have hit a raw nerve. I'm sorry." b. "You are angry. Let's talk about the issue." c. "Please watch your tone of voice when you speak to me." d. "I don't think I deserved to be shouted at. What's really the matter?"
ANS: B To be of maximal benefit to the patient, anger should be accepted and explored. Apologies by the nurse are unnecessary. The other options are defensive and rigid reactions.
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.
7. A clinic nurse encounters a new patient diagnosed with schizoid personality disorder. What is the best initial nursing intervention? a. Set firm limits. b. Engage in trust building. c. Involve the patient in group activities. d. Encourage identification of feelings.
ANS: B Trust building is essential to developing a nurse-patient relationship. Firm limit-setting is rarely necessary when working with a patient with schizoid personality disorder. Involvement in activities might be difficult at first, because the patient will be highly uncomfortable around people. The patient must trust the nurse before responding to encouragement to express feelings.
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.
8. The nurse cares for a client who experienced a violent assault and battery attack. When considering the need to communicate with the client, what is the most therapeutic intervention? a. Discourage expression of feelings until the victim enters the recoil stage. b. Demonstrate empathetic communication techniques. c. Educate the victim about strategies to avoid attacks in the future. d. Maintain a matter-of-fact manner, and remain objective.
ANS: B Victims of violence require the nurse to provide unconditional acceptance of them as individuals, because the victim often feels guilty and engages in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and promote establishment of trust.
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.
6. Which statement forms the foundation upon which a nurse should base the implementation of psychotherapeutic management to the care of a patient with mental illness? a. The nurse's role in client care is supported by the multidisciplinary team. b. Omitting any one component will compromise the effectiveness of the treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse-patient relationship is the most important aspect of treatment.
ANS: B When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients' needs govern the application of the components and permit judicious use. The remaining options identify components of the psychotherapeutic management process.
9. What assessment question asked by the nurse planning care for an older client best minimizes the risk for ineffective medication administration by the client and impaired medication effectiveness? a. "What do you expect this medication will do for you?" b. "Can you explain how and when you should take your medication?" c. "How many medications do you take each day?" d. "Will you be able to easily get your medication prescriptions refilled?"
ANS: B While many factors contribute to the effective self-administration of medications, an adequate understanding of the instructions related to the medications' administration is of primary importance to achieving medication-related goals.
2. When discussing the precedent established in Wyatt v. Stickney with nursing students, the nurse demonstrates an accurate understanding or the decision by focusing on what factor? a. Intellectualization of the client's condition b. About the client's rights to adequate treatment c. Minimizing the client's risk of being coerced into treatment d. Risks created by a request for immediate discharge from the facility
ANS: B Wyatt v. Stickney was a case in which the court ruled that patients had the right to adequate treatment while hospitalized. Intellectualizing is a defense mechanism. Right to refuse treatment and commitment issues were not the focus of Wyatt v. Stickney.
2. A nurse cares for patients who recently immigrated to the United States. The nurse would expect patients from which countries to hold relational worldviews? (Select all that apply.) a. Germany b. Panama c. Mexico d. Ghana e. France
ANS: B, C, D Persons of Hispanic and African-American cultures often hold relational worldviews. Mexico and Panama are predominantly Hispanic cultures. Ghana is African. Immigrants from Germany and France (European countries) would more likely have analytic worldviews.
1. Which changes in psychiatric nursing practice are directly attributable to events occurring during the Decade of the Brain? (Select all that apply.) a. Homeless shelters became practice sites. b. Nurses upgraded knowledge of psychopharmacology. c. Nurses provided psychoeducation to patients and families. d. Nurses viewed psychiatric symptoms as resulting from brain irregularities. e. Nurses were more likely to advocate for patients' rights related to involuntary commitment.
ANS: B, C, D Psychobiologic research relating to brain structure and function made it possible for psychiatric nurses to view symptoms as brain irregularities and made it necessary for them to become knowledgeable about psychotropic medications to make appropriate assessments regarding desired outcomes and side and toxic effects of therapy. With hospital stays shortened, it became necessary for nurses to provide psychoeducation to patients and families who would need to monitor outcomes, symptoms of relapse, and side and toxic effects of medication. Homeless shelters became practice sites with the onset of deinstitutionalization. Advocacy for patients' rights relating to hospitalization and commitment became an ethical issue before the Decade of the Brain.
2. A patient cries as the nurse explores the patient's feelings about the death of a close friend. The patient sobs, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse facilitate communication? (Select all that apply.) a. "Why do you think you are so upset?" b. "I can see that you feel sad about this situation." c. "The loss of your friend is very painful for you." d. "Crying is a way of expressing the hurt you're experiencing." e. "Let's talk about something else, since this subject is upsetting you."
ANS: B, C, D Reflecting and giving information are therapeutic techniques. "Why" questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.
A caregiver tells the nurse at the mental health clinic, "My parent has changed over the past 2 months. Decision making is almost impossible. My parent sits and stares in space all day. There has been a 12-pound weight loss." What additional assessment data should the nurse gather to determine whether the depression is primary or secondary to another problem? Select all that apply. a. Cultural heritage b. Medical problems c. List of current medications d. Alcohol and/or substance use e. Presence of suicidal ideation strategies
ANS: B, C, D, E Depressive symptoms in older adults might be caused by a variety of medical illnesses, including dementia, and by a variety of medication side effects. Alcohol and substance abuse might be a causative factor in the appearance of depression. Increased stressors suggest that this might be depression caused by MDD. Suicidal ideation is important to assess regardless of cause, because older adults are at increased risk for suicide. If depression is secondary to another cause, the primary cause is treated and the depression might improve. If the depression is primary, treatment for depression should be instituted. The nurse is often the individual who elicits important history. Cultural factors would have less bearing on causation.
9. A nurse teaches a class about bulimia nervosa to high school biology students. The nurse should provide what neurotransmitter process as a possible cause of this eating disorder? a. Hypersensitivity of norepinephrine b. Excessive dopamine activity c. Overproduction of GABA d. Serotonin deficits
ANS: D Based on a few research studies, current thinking suggests that deficits in serotonin might play a role in bulimia nervosa. There is no research to support the correctness of any of the other options.
3. What information about a patient's perceptions and values would the nurse obtain by using questions from the HOPE tool? (Select all that apply.) a. Healthy spirituality versus sick religiosity b. That which gives the patient hope and meaning in life c. Important personal spiritual practices d. Role of religion in the patient's life e. Sources of strength and comfort
ANS: B, C, D, E The HOPE questions gather information about sources of hope, strength, comfort, meaning, peace, love, and connection; the role of organized religion for the patient; personal spirituality and practices; and effects on medical care and end-of-life decisions. Healthy spirituality versus sick religiosity is not addressed in this tool.
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. Which techniques are therapeutic when interacting with a patient? (Select all that apply.) a. Avoiding direct questions b. Validating and clarifying c. Using empathy sparingly d. Assuming an attending posture e. Maintaining constant eye contact
ANS: B, D Using validation and clarification ensures that the nurse understands what the patient is saying. Using an attending posture conveys the message that the nurse is interested in what is being communicated. Giving feedback appropriately conveys interest and understanding. The other options are ineffective behaviors.
Which topics should be included by the nurse preparing psychoeducational groups for patients with major depressive disorder and their families? Select all that apply. a. Flight of ideas b. Changes in weight and sleep c. Feelings of importance or elation d. Psychomotor retardation or agitation e. Inability to concentrate or make decisions
ANS: B, D, E Patients with MDD characteristically display weight change—anorexia produces weight loss, and excessive eating produces weight gain. Sleep disturbance is characteristically present in MDD, with many or early awakenings and hypersomnia seen. Changes in activity include psychomotor retardation and excessive motor agitation. Indecision and poor concentration are characteristic cognitive symptoms. Flight of ideas and increased energy, importance, and elated mood are seen in bipolar disorder, manic type.
1. What data should a nurse analyze when deciding to refer a patient with a psychiatric disorder to community-based care? (Select all that apply.) a. Need for PRN medication b. Severity of the patient's illness c. Need for structured formal therapy d. Presence of suicidal or homicidal ideation e. Amount of supervision required by the patient
ANS: B, D, E The decision tree for the continuum of care calls for the assessment of severity of the illness, the presence or absence of suicidal or homicidal ideation, whether or not the disability is so great that the patient is unable to provide for his or her own basic needs, and the amount of supervision required for patient safety. The frequency of need for PRN medication and the need for structured formal therapy are not considerations mentioned in the decision tree.
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.
2. A leader beginning the discussion at the first meeting of a new group can appropriately include what statement? (Select all that apply.) a. "We use groups to provide treatment, because it's a more cost-effective use of staff in this time of budget constraints." b. "When someone shares a personal experience, it's important to keep the information confidential." c. "Talking to family members about our group discussions will help us achieve our goals." d. "Everyone is expected to share a personal experience at each group meeting." e. "It is important for everyone to arrive on time for our group."
ANS: B, E The leader must set ground rules for the group before members can effectively participate. Confidentiality of personal experiences should be maintained. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. While groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.
10. Which intervention should the nurse implement when focusing on communicating therapeutically with a client? a. Explaining to the client why they will need to ask for a razor b. Providing the client with options to help achieve smoking cessation c. Encouraging the client to identify personal stressors d. Assuring the client that they can receive telephone call on the unit telephone
ANS: C A nurse uses therapeutic communication techniques as part of the therapeutic nurse-patient relationship. An example of such communication is providing the client with an opportunity to safely identify personal stressors. The remaining options address safety, balance, and norms associated with their care.
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.
The nurse sees a depressed patient who has psychomotor retardation leaving the dining room. The patient's shirt is soiled from spilled food. The nurse should: a. foster independence by suggesting changing shirts. b. ignore the spill to avoid embarrassing the patient. c. assist the patient to change into a clean shirt. d. notify the patient of the soiled shirt.
ANS: C A patient with psychomotor retardation might need assistance with hygiene and grooming. It is important for the nurse to help the patient appear well groomed so as to avoid embarrassment. Ignoring the situation is nontherapeutic. The patient should be assisted by staff. The patient might not have the physical energy to respond to a suggestion.
6. An anxious, withdrawn patient is experiencing auditory hallucinations. The nurse should arrange for the patient to be enrolled in which group? a. Recreation b. Insight-oriented c. Reality orientation d. Stress management
ANS: C A reality orientation group is a type of support group for patients who have confusion and short attention spans and who might be frightened, anxious, and isolated. The focus is on the "here and now," which is an aid to reality testing. The other types of groups would not be as beneficial since they require the members to be more stable both cognitively and emotionally.
7. What is the primary purpose of referring a patient to an activity group? a. Assess the patient's social skills. b. Provide cognitive and sensory stimulation. c. Encourage socialization and communication. d. Educate the patient about use of leisure time.
ANS: C Activity groups are vehicles to facilitate patient interaction and communication with others and provide enjoyment. Although the other options are true, they are secondary in nature.
A patient is to have a dexamethasone suppression test in the morning. Which statement should be included in patient teaching? a. "This test will determine whether or not you are clinically depressed." b. "This test is like a CT scan. It will take about 20 minutes and will be painless." c. "You will be given an injection; then, blood and urine samples will be collected." d. "You will not be allowed to eat or drink after midnight, and a fasting blood sample will be collected in the morning."
ANS: C After the dexamethasone is given, periodic blood and urine samples are collected and sent to the laboratory to determine whether or not cortisol suppression has occurred.
17. Which type of group is a staff nurse with 2 months' psychiatric experience best qualified to conduct? a. Social skills group b. Family therapy group c. Medication education group d. Insight-oriented psychotherapy group
ANS: C All nurses receive information about patient teaching strategies and basic information about psychotropic medications, making a medication education group a logical group for a beginner to conduct. All the other options require more advance mental health care knowledge and experience than a novice nurse processes.
9. A soldier who served in a combat zone returned home to the United States. The soldier's spouse reports to the nurse, "We had planned to start a family right away, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD? a) Reexperiencing b) Hyperarousal c) Avoidance d) Psychosis
ANS: C Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence that this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.
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.
18. A combat veteran diagnosed with moderate traumatic brain injuries is agitated and aggressive. Which pharmacologic intervention would the nurse expect to be effective? a) Bupropion (Wellbutrin) b) Benztropine (Cogentin) c) Propranolol (Inderal) d) Buspirone (BuSpar)
ANS: C Beta blockers such as propranolol (Inderal) effectively manage agitation and aggression in persons with TBIs. A dopamine-norepinephrine reuptake inhibitor such as bupropion would increase agitation. Anxiety is not the central problem for this patient. The patient does not have extrapyramidal side effects or Parkinson's disease.
4. A nurse will prepare teaching materials regarding which drug for the parents of a child diagnosed with ADHD? a. Paroxetine b. Imipramine c. Methylphenidate d. Carbamazepine
ANS: C Central nervous system (CNS) stimulants are the drugs of choice for treating children with ADHD. Methylphenidate and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD.
The nurse working with a patient diagnosed with borderline personality disorder expects: a. grief and social isolation. b. withdrawal and social avoidance. c. mood shifts, impulsivity, and manipulation. d. seductiveness, grandiosity, and overreaction.
ANS: C Characteristic behaviors of individuals with borderline personality disorder include rapid mood shifts, impulsive acting out, and manipulation of others, as well as problems with identity, dependency, self-mutilation, and unstable, intense interpersonal relationships.
11. A patient diagnosed with an eating disorder asks to be excused from a meal to use the restroom. What is the nurse's best response to the patient's request? a. "No one is permitted to leave the table during meals." b. "You may go after you've finished your meal." c. "I will go with you to the restroom." d. "No. I know you want to vomit."
ANS: C Close observation is necessary to prevent patients with eating disorders from purging during and after meals. Patients should be accompanied to the bathroom and observed while in the bathroom to prevent purging. Bargaining, lying, and judgmental confrontation are not appropriate responses.
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.
10. An adult with serious mental illness is being admitted to a community behavioral health inpatient unit. Recognizing current trends in hospitalization, the nurse can reasonable assume the need to prioritize which intervention? a. Providing education regarding the need for medication adherence b. Evaluating whether the client has a clear understanding of the illness c. Implementing safety precautions to address aggressive behavior d. Counseling the client concerning risks involved in demanding discharge against medical advice
ANS: C Compared with patients of the 1960s and 1970s, today's patients are likely to display more aggressive behavior. This understanding is critical to making astute assessments that lead to planning for the provision of safety for patients and staff. Treatment compliance, understanding of the illness process, and discharge against medical advice are possible issues with which the nurse might deal, but these are less relevant when admission assessment is performed.
13. A patient tells the nurse, "This medicine makes me feel weird. I don't think I should take it anymore. Do you?" The most effective reply that the nurse could make is based on which psychotherapeutic management model? a. Psychopathology b. Milieu management c. Psychopharmacology d. Therapeutic nurse-patient relationship
ANS: C Concerns about medication voiced by patients require the nurse to have knowledge about psychotherapeutic drugs to make helpful responses. The nurse-patient relationship component is based on use of self. Milieu management is concerned with the environment of care. Psychopathology provides foundational knowledge of mental disorders but would be less relevant in framing a response to the patient than knowledge of psychopharmacology.
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.
2. A patient at the clinic describes periods of sadness and depression as well as episodes of elation over the past 3 years. The patient adds, "Fortunately, I have been able to keep my job despite these mood changes." These findings are most consistent with which disorder? a. Bipolar I b. Bipolar II c. Cyclothymic d. Seasonal affective
ANS: C Cyclothymic disorder is characterized by mood swings between hypomania and depressive symptoms, with behavior at the poles being less severe than mania or depression. The patient's ability to remain employed indicates that the periods of elation were hypomania rather than mania. The patient's description does not meet criteria for any of the other options listed.
12. A patient moans, "God wants me to suffer, but I don't know why. I feel like an outcast. I should have never been born." Which nursing diagnosis should the nurse include in patient's plan of care? a. Potential for enhanced spiritual well-being b. Disturbed personal identity c. Spiritual distress d. Powerlessness
ANS: C Defining characteristics for the nursing diagnosis of spiritual distress are present. They include concern with the meaning of life, anger toward God, questioning the meaning of suffering, conflict about beliefs, and questions about the morality of the therapeutic regimen. Spiritual distress is more applicable to the patient's comments than the other diagnoses.
13. The nurse asks members of a group for recovering alcoholics how they handle the urge to drink. Which communication technique is the nurse using? a. Summarizing b. Presenting reality c. Encouraging comparison d.Seeking consensual validation
ANS: C Distinguishing among the techniques listed shows that the nurse is encouraging comparisons. Asking members to compare and contrast their experiences promotes group sharing. None of the other options focus on the comparison identified in the question.
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.
23. After an episode of self-mutilation, a patient diagnosed with borderline personality disorder will begin individual therapy and group skills training. The goals are to decrease use of dissociation, increase distress tolerance, and regulate affect. Which type of therapy is evident? a. Rational-emotive behavioral b. Motivational enhancement c. Dialectical behavioral d. Interpersonal
ANS: C Each of the components described in the scenario is a component of dialectical behavioral therapy. The scenario information is not consistent with the components of any of the other types of therapy given as options.
12. Which behavior would relevant to a potential diagnosis of Exhibitionism? a. Engaging in "Peeping Tom" behaviors b. Going out in public dressed as a member of the opposite gender c. Exposing one's genitalia while in a movie theater d. Engaging in strangulating behaviors to enhance sexual pleasure
ANS: C Exhibitionism is obtaining sexual pleasure from exposing one's genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. The primary characteristic of transvestic disorder is sexual arousal derived from cross-dressing or dressing as the opposite sex. Sexual masochism sometimes involves erotic asphyxiation as a means of enhancing arousal.
7. A patient excitedly tells the nurse, "Look what I made in arts and crafts! I did a good job. I want to make some other things too." The nurse may conclude that which part of the patient's nervous system is responsible for processing this reaction? a. Brain stem b. Occipital lobe c. Limbic system d. Corpus callosum
ANS: C Feelings of pleasure are generated in the brain's limbic system. The exact mechanisms of generating emotions and motivation, however, are unclear. The other structures are not involved in pleasure or motivation processing.
1. A person says, "What mental health issues are a major concern for the general population." The nurse's reply should be based on what confirmed fact concerning mental health issues? a. Bipolar disorder is a rare diagnosis among the general population. b. A diagnosis of schizophrenia is rarely confirmed during the teenage years. c. Major depression is very prevalent among the adult population. d. Alcohol-related issues are minimal considering the entire adult population.
ANS: C Four of the top medical disorders causing disability are psychiatric disorders (i.e., major depression, schizophrenia, bipolar disorder, and alcohol abuse). About half of all mental disorders start by the midteens.
9. A patient has difficulty expressing anger appropriately. The nurse encourages the patient to set realistic goals by making what statement? a. "You seem to have problems expressing anger in a nonaggressive way." b. "I thought you sounded angry when I told you it was time for group." c. "What do you think needs to change about how you express anger?" d. "What bothers you about your actions when you get angry?"
ANS: C Goal-setting is most directly related to the technique of asking patients to decide on the type of change needed. The distracters demonstrate making observations and exploring.
2. Which behavior indicates that the treatment plan for a 5-year-old child diagnosed with autistic disorder has been effective? a. Is content to play with one toy for hours. b. Repeats words spoken by a parent. c. Holds the parent's hand while walking. d. Finds enjoyment in clapping his or her hands while walking.
ANS: C Holding the hand of another person suggests relatedness. Usually, a child with autism would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The other options reflect behaviors that are consistent with autistic disorder.
1. A soldier was diagnosed with post-traumatic stress disorder (PTSD). The soldier's spouse reports that when a telephone rings during the night, the soldier rolls out of bed and assumes an aggressive stance. How will the nurse document this finding? a) Flashback b) Avoidance c) Hyperarousal d) Reexperiencing
ANS: C Hyperarousal includes exaggerated responses to noises and other environmental stimuli. It is part of the constellation of problems that impair sleep for persons with PTSD. Flashbacks are an aspect of reexperiencing. Avoidance is another criterion for PTSD.
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.
An adult has a history of intoxication and promiscuity. After stealing money from a grandparent, this person says, "I deserved that money. My family had no right to press charges against me." The scenario depicts features of which personality disorder? a. Histrionic b. Narcissistic c. Antisocial d. Borderline
ANS: C Individuals with antisocial personality disorder have no concern for what is right or wrong or for the rights of others. They frequently violate others' rights and frequently break laws in their "me first" thinking. These individuals exhibit no guilt or remorse. Narcissistic personality disorder is characterized by grandiosity and a sense of entitlement. Borderline personality disorder is characterized by identity disturbances, impulsivity, self-mutilation, and affective instability.
Which behaviors are expected in patients diagnosed with avoidant personality disorders? a. Social aptitude; risk taking b. Promiscuity; impulsiveness c. Shyness; poor self-confidence d. Attention seeking; helplessness
ANS: C Individuals with avoidant personalities desire relationships but keep their anxiety at a low level by avoiding situations in which they might experience rejection. They are timid, uncertain, and often withdrawn. The other options describe behaviors that would not be seen in patients with avoidant personality disorder.
10. A patient diagnosed with schizophrenia, paranoid type, has been suspicious of staff since admission. The patient visits with a chaplain but then tells the nurse, "Don't send any more preachers." What is the most likely reason for the patient's reaction? a. Hostility b. Distractibility c. Inability to trust d. Inability to find meaning in suffering
ANS: C Individuals with paranoid schizophrenia often have an inability to trust. Inability to trust may be related to inadequate nurturing in infancy and to later difficulty recognizing a connection with God. The other options are less clearly related to issues of paranoia and trust.
16. The clinic nurse sees a patient with a long-standing diagnosis of pedophilia who was recently arrested and released on bail. Which perspective about pedophilia would the nurse expect from this patient? a. Extreme remorse for traumatizing a child to meet his or her own needs. b. Desire to be placed in jail to prevent acting on the sexual impulses. c. The belief that the child was given valuable knowledge and pleasure. d. A feeling of victimization related to genetic and environmental factors.
ANS: C Individuals with pedophilia frequently do not believe that their behavior is harmful to the child. Instead, they point to having provided teaching and pleasure for the child. The other options are not characteristic of the thinking of the pedophile.
15. A nurse presents a psychoeducational program to patients with bipolar disorder and their families. Information about signs of impending relapse of depressive episode should include: a. diarrhea, thirst, and gross tremor. b. sleep disturbances and racing thoughts. c. decreased libido, anhedonia, and inertia. d. anorexia, excessive guilt, and aggression.
ANS: C Relapse symptoms are congruent with early symptoms of a depressive episode. They include decreased libido, loss of pleasure, and lack of energy. Sleeping less, experiencing racing thoughts, experiencing aggression, and having boundless energy suggest impending mania. Diarrhea, thirst, and tremor relate to lithium side effects.
A 74-year-old patient is admitted with anhedonia, weight loss of 20 pounds in 6 weeks, and pervasive guilt over issues that occurred in early adulthood. The patient is diagnosed with melancholic depression. Which intervention has the highest priority for inclusion in the care plan? a. Assess history of seasonal variations of mood. b. Observe for increased sensitivity to rejection. c. Monitor and document sleep patterns. d. Assess for echolalia and posturing.
ANS: C Individuals with the depressive variant of melancholia often display anhedonia, depression worse in the morning, early morning awakening, anorexia and/or weight loss, and inappropriate guilt. It is appropriate to monitor sleep patterns to ascertain if sleep disturbance is present. Homeostasis is contingent on adequate sleep. The distracters are seen in depression with catatonic features, atypical depression, and seasonal affective disorder.
17. Which patient behavior should be considered when evaluating the need for an involuntary commitment for psychiatric treatment? a. Noncompliant with the treatment regimen b. Engaging in the selling and distribution of illegal drugs c. Verbalizing the threat to "eliminate anyone who comes near me" d. Living on the streets
ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization since there is not direct threat of harm to self or to others.
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. Which characteristic fits the profile of an individual who is a pedophile? a. Homosexual b. High self-esteem c. Seeks access to children d. Self-confident and expressive
ANS: C It is known that pedophiles usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilia.
4. A patient says, "I know I need religion in my life, but I don't know how to find God. I feel I have been abandoned." The nurse should assess for a childhood history of what experience? a. Recurrent losses b. Overindulgence c. Lack of nurturing d. Poor school performance
ANS: C Loder has hypothesized that early developmental experiences set the stage for later spiritual dynamics. Inadequate nurturing may result in lack of establishment of trust. Later, spiritual issues of abandonment and shame might surface. None of the other options have been advanced as explanations for feelings of abandonment by God.
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
21. At the time of discharge, a patient with a European-American analytic worldview demands copies of all medical records. Which truth about the patient's values most accurately explains the patient's behavior? a. Continues to experience mistrust of the team's truthfulness. b. Is probably planning to see an attorney about poor care. c. Values the written evidence of illness and treatment. d. Probably wants to edit the records for accuracy.
ANS: C Members of European-American cultures have analytic worldviews and value information that is written because it lends proof. The distracters offer more remote reasons for the behavior.
11. A nurse demonstrates an understanding of milieu management associated with the care of older client's diagnosed with psychiatric disorders when implementing which interventions? a. Provide cognitive-behavior therapy (CBT) for all patients. b. Provide unconditional acceptance of all client behaviors. c. Prevent clients from self-isolating. d. Limit time clients spend reminiscing.
ANS: C Nurses have a responsibility to facilitate optimal function. Attention to the milieu can increase psychological functioning and prevent deterioration resulting from withdrawal and disuse of skills. Unconditional acceptance of the individual is appropriate, but not all behavior must be accepted. It would be impractical to provide CBT for all patients. Reminiscence is a positive activity that should be encouraged and integrated into a plan of care.
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.
5. Prior to working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care would require what personal characteristic? a. Sympathy b. Assertiveness training c. Sexual self-awareness d. Effective communication
ANS: C Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distracters are not prerequisites.
A patient diagnosed with borderline personality disorder has demonstrated self-mutilation and inappropriate expressions of anger. Which statement by the patient would the nurse evaluate as an improvement? a. "I think you are the nicest nurse on the unit." b. "I got drunk last night, but I won't ever do it again." c. "I felt like cutting myself, so I came to talk to you." d. "I hate my friends. They never help me when I need it."
ANS: C Ordinarily, the patient would impulsively engage in self-mutilation. When he or she is able to delay the action and seek the more adaptive coping strategy of talking with the nurse, the nurse can correctly evaluate the patient as showing improvement. The other responses suggest use of idealization, manipulation, impulsive behavior, and devaluation, all symptomatic of the disorder.
9. A patient tells the nurse, "I still have suicidal thoughts, but don't tell anyone because I am supposed to be discharged today." Select the nurse's best course of action. a. Have the patient sign a "no suicide" contract. b. Respect the patient's request related to confidentiality. c. Inform the health care provider and other team members. d. Search the patient's belongings for potentially hazardous items.
ANS: C Patient right to confidentiality never includes keeping important clinical information secret, especially information related to patient safety. Patients should be informed that all relevant information will be shared with the health care team. None of the other options sufficiently address the safety issue presented by a patient who expresses suicidal thoughts.
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.
5. A clinic nurse encounters many patients who request acupuncture, nutritional therapies, moxibustion, cupping, and coining. The nurse understands that these patients are seeking to restore what personal characteristic? a. Chi b. Meridians c. Equilibrium d. Divine relationships
ANS: C Patients who view illness as disequilibrium or lack of balance may seek alternative therapies to restore balance. Chi is an energy force. Meridians are lines in the body representing body functions. Divine relationships are an aspect of balance, but equilibrium is a broader concept.
5. A patient diagnosed with anorexia nervosa spills milk over a plate of partially eaten food. What is the nurse's best response to facilitate effective patient care? a. "That won't work. You are manipulating." b. "You are deliberately making mealtime difficult." c. "I will get you a fresh plate of food so you can finish." d. "You must eat your meal. I'll wait until you finish."
ANS: C Patients with anorexia nervosa often use strategies to hide food, spill food, or discard it to avoid eating. The nurse can best handle these behaviors with nonjudgmental confrontation and adherence to established limits. Only the correct answer is a nonjudgmental response. The other options are judgmental or punitive.
8. A patient admitted to an inpatient unit after a suicide attempt says, "I feel so overwhelmed. There are so many issues I have to deal with." The nurse should schedule the patient to attend which type of group to meet their initial needs? a. Social skills b. Psychodrama c. Problem-solving d. Medication information
ANS: C Problem-solving groups teach the skills necessary to solve problems. A patient with multiple problems will benefit from learning the process for problem-solving, because the multiple problems to which he or she refers probably will not be resolved during a short inpatient stay. The scenario does not pose problems with social skills or medication. Psychodrama is rarely offered in an inpatient setting.
2. Which component of the nursing process will the nurse focus upon to address the responsibility to match individual patient needs with appropriate services? a. Planning b. Evaluation c. Assessment d. Implementation
ANS: C Proper assessment is critical for being able to determine the appropriate level of services that will provide optimal care while considering patient input and at the lowest cost. Planning and implementation utilizes the assessment data to identify and execute actions (treatment plan) that will provide appropriate care. Evaluation validates the effectiveness of the treatment plan.
12. Risk assessment for a patient shows these findings: schizophrenia but not currently; not a danger to self or others; lives in parents' home. Which decision regarding placement on the continuum of care is appropriate? a. Hospitalize the patient. b. Discharge the patient from the system. c. Refer the patient to outpatient services. d. Refer the patient to self-help resources in the community.
ANS: C Referral should be made to the least restrictive, most effective, and most cost-conscious source of services. Because the patient is not a danger to self or others, hospitalization is not needed. However, follow-up as an outpatient would be more appropriate than referral to a self-help group, in which structure might be lacking, or discharge from the system.
6. The nurse is establishing treatment goals for a person who was a victim of mind control and physical abuse. What is the initially focus goal for this individual? a. Making independent personal decisions b. Repressing emotions experienced during the abuse c. Re-establishing relationships with support persons d. Using desensitization strategies to restore equilibrium
ANS: C Relationships with family and former friends are invariably disrupted based on the victim's inability to trust. Re-establishing relationships would be the first step toward reorganization. Later, the victim will be able to make independent decisions for herself. Repression and desensitization are not the initial desirable outcomes since the client needs to work on reintegrating into the world.
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.
11. During the risk assessment phase of care for a psychiatric patient, what is the nurse's primary goal? a. Making an initial assessment b. Confirming the patient's problem c. Assessing potential dangerousness to self or others d. Determining the level of supervision needed for the patient
ANS: C Risk assessment involves looking at dangerousness to self or others, the degree of disability, and whether or not the individual is acutely psychotic to determine the feasibility of community-based care versus hospital-based care. Risk assessment usually follows the initial assessment. Confirmation of the patient's problem is not part of the risk assessment protocol. Arranging entry into the mental health system will follow risk assessment if the patient is assessed as needing service.
3. A patient shouts, "I'm holding you responsible for mistreatment based on Rogers v. Orkin." The nurse should review past care related to what focus? a. Loss of privileges b. Inability to make phone calls c. Medication administration d. Involuntary hospitalization
ANS: C Rogers v. Orkin was a case in which the court ruled that nonviolent patients could not be forced to take medication. It did not have implications related to hospitalization or application of patient privileges.
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.
A nurse involved in a research study for biologic markers of depression will expect to prepare patients to undergo which diagnostic procedures? a. MRI, CBC, and TSH tests b. PET scan and a waking EEG c. Sleep EEG, DST, and TSH tests d. GABA suppression test and 5-HT serotonin ratio
ANS: C Several biologic markers are being studied to advance understanding of depression. These include sleep EEGs to determine the role of decreased REM latency, DST, and TSH test to determine the role of hypothalamic-pituitary-adrenal dysregulation. Two options refer to actual diagnostic tests, but these tests are not being used to investigate depression. The last option refers to tests that are not actual tests.
3. A patient's medical record documents sexual masochism. Which behavior supports this diagnosis? a. Arousal is possible only when masturbating with women's underwear. b. Organism is achieved by inflicting pain on a sexual partner. c. Sexual pleasure is a result of sexually humiliated by a partner. d. Arousal results from the sexual touching of a nonconsenting person.
ANS: C Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.
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.
17. Which of these services is most appropriate for an older client requiring minimal mental health interventions? a. Day treatment b. Hospitalization c. Scheduled visits at a community mental health center d. Regular attendance at a senior center facility
ANS: C The continuum of care represents treatment services along a range of intensity. Hospitalization is the most intensive, progressing to day treatment, and finally to routine visits at a community mental health center. A senior center is not prepared to provide mental health interventions.
9. A child diagnosed with attention-deficit hyperactivity disorder (ADHD) had this nursing diagnosis—impaired social interaction, related to excessive neuronal activity, as evidenced by aggressiveness and dysfunctional play with others. Which finding indicates the plan of care was effective? a. Improved ability to identify anxiety and use self-control strategies. b. Increased expressiveness in communication with others. c. Engages in cooperative play with other children. d. Increased responsiveness to authority figures.
ANS: C The goal should be directly related to the defining characteristics of the nursing diagnosis; in this case improvement in the child's aggressiveness and play. The distracters are more relevant for a child with pervasive developmental disorder or anxiety disorder.
8. Within a 15-minute period, a patient having a manic episode voices these complaints. "Dinner was cold. The bath towels are rough. The solarium is too hot. I have a sore throat. Another patient needs a shower. The medication nurse is too slow." The nurse should: a. listen but ignore the patient's complaints. b. tell the patient to use the suggestion box. c. assess the patient's throat, and take vital signs. d. invite the patient to share the concerns at the community meeting
ANS: C The hypercritical manic patient offers so many complaints that it is easy to discount his or her concerns. Legitimate complaints should always be investigated, however. By listening and ignoring complaints, the nurse might fail to intervene to provide care. Telling the patient to use the suggestion box or asking him to share his complaints at the community meeting are placating and may anger the patient.
19. Personality traits most likely to describe a patient diagnosed with obsessive-compulsive personality disorder are: a. friendly; generous. b. dramatic; impulsive. c. perfectionist; inflexible. d. suspicious; submissive.
ANS: C The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with this personality disorder.
22. As members disperse at the conclusion of a productive group meeting, one member says, "Let's have a big group hug." What is the leader's most appropriate response? a. "Hugging is not permitted." b. "I am glad you found the meeting so helpful." c. "Thanks for that suggestion, but not everyone may be comfortable with hugs." d. "The group is over now. Members may not have continued contact with each other."
ANS: C The leader must facilitate maintenance of the group norms. Some persons may feel comfortable with hugs; others may not. The leader should not prohibit the behavior but rather should gently set limits that recognize the needs of all.
4. The nurse plans discharge teaching for a patient who experienced a stroke involving the hippocampus. The nurse should adapt the teaching plan to account for possible problems with which function? a. Visual acuity b. Expressive aphasia c. Short-term memory d. Balance and coordination
ANS: C The limbic system is crucial to memory. Damage to the hippocampus, a part of the limbic system, causes problems converting short-term to long-term memory, making learning difficult. Aphasia is a temporal lobe problem. Blindness is an occipital lobe problem. Balance and coordination are affected by damage to the cerebellum.
A patient says, "The doctor said I have dysthymic disorder." What priority assessment data should the nurse obtain to confirm the diagnosis? a. Changes in appetite and weight b. Presence of suicidal ideation c. How long symptoms have persisted d. Presence of delusions or hallucinations
ANS: C The major distinguishing factor between MDD and dysthymic disorder is the fact that dysthymic disorder has persisted for 2 years or more, with low mood occurring more than 50% of the time. It is a disease of chronicity, whereas MDD is a disease of severity. Suicidal ideation can be present in any type of depression. Delusions and hallucinations are noted primarily in psychotic depression.
7. During community lunch, a manic patient tells another patient, "Push yourself away from the table. You're too fat for your own good!" How should the nurse intervene? a. Say to the patient, "You may remain at lunch only if you apologize." b. Tell the patient, "You must leave lunch and go to your room now." c. Calmly tell the patient that insulting others is not permitted. d. Extinguish the behavior by ignoring it.
ANS: C The nurse must protect vulnerable patients and keep them from being drawn into the manic patient's angry behavior. By stating that the behavior is not permitted, the nurse sets limits and does not enter into an argument. The distracters will further anger the patient, may cause escalation, or may allow for loss of control
Which nursing diagnosis is almost universally applicable to persons with depression? a. Ineffective denial b. Disturbed body image c. Chronic low self-esteem d. Risk for other-directed violence
ANS: C The overall affective sense of the depressed person is one of low self-esteem. Guilt often accompanies the low self-esteem. Data about depressed individuals do not suggest the applicability of body image disturbance. Denial and risk for violence may or may not be present.
13. An involuntarily admitted inpatient diagnosed with paranoid schizophrenia repeatedly calls the local mayor. The patient verbally abuses the person who answers the phone as well as the mayor. Select the most appropriate initial nursing intervention to help manage this behavior. a. Document the behavior and inform the patient that their phone privileges could be revoked. b. Include the patient in a social skills building group. c. Suspend the patient's phone privileges temporarily, and document the reason. d. Ask the patient advocate to review the limits of the patient's rights with the patient.
ANS: C The patient requires a consequence for unacceptable behavior. The nurse should document that the patient's calls violated the rights of others, thus providing a basis for temporary suspension of the right to make phone calls to the mayor's office. Allowing continued calls violates the rights of others. It might require several days for the advocate to meet with the patient. Social skill building is valuable but doesn't address the immediate behavior.
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.
When contrasting schizophrenia and schizotypal personality disorder, which statement applies? a. In schizotypal personality disorder, the patient remains psychotic much longer. b. The patient with schizophrenia has better social skills and is not usually overtly psychotic. c. The person with schizotypal personality disorder may have cognitive distortions but not psychosis. d. Schizotypal personality disorder is associated with more frequent and prolonged hospitalizations
ANS: C The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, overt psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, have poorer social skills, and have more frequent and prolonged hospitalizations.
14. Although a patient appears to have recovered from a head injury resulting from an auto accident 3 months ago, the family reports changes in the patient's personality and behavior. The nurse should explain that these changes are probably associated with injury to which structure? a. Pons b. Parietal lobe c. Prefrontal area d. Caudate nucleus
ANS: C The prefrontal area is the seat of personality. It is responsible for thought, goal-oriented behavior, and inhibition. The other structures have less significant roles in personality change.
A patient with depression paces, pulls at clothing constantly, and cannot sit for longer than 5 minutes. The patient ruminates about being a "bad" person. Select the most effective nursing intervention. a. Reassure the patient. b. Direct the patient to lie down every 2 hours. c. Ask the patient to assist in a simple, repetitive activity. d. Seek a prescription for a PRN antipsychotic medication.
ANS: C The psychomotor energy of agitation might be channeled into simple, repetitive activities. Providing an activity that is of value to others can help relieve guilt. As for the other options, the patient will be unable to lie down, global reassurance is ineffective, and an antipsychotic medication is not indicated.
3. A nurse is preparing to present a discussion to a group of nursing students on meeting the needs of the mentally ill. What concerns should be identified as the focus of society's concerns during both the Period of Enlightenment and the Period of Community Mental Health? a. Moving patients out of asylums b. Studying brain structure and function c. Meeting basic human needs humanely d. Providing medication to control symptoms
ANS: C The use of asylums signaled concern for meeting basic needs of the mentally ill, who in earlier times often wandered the countryside. With deinstitutionalization, many patients who were poorly equipped to provide for their own needs were returned to the community. The current system must now concern itself with ensuring that patients have such basic needs as food, shelter, and clothing. Studying brain structure and function is more a concern of modern times, as is t
19. A patient with a long history of multiple sclerosis developed psychosis with acute mania. The nurse should anticipate that the health care provider will probably prescribe which medication to help stabilize the mania? a. Lithium (Lithobid) b. Amitriptyline (Elavil) c. Divalproex (Depakote) d. Diphenhydramine (Benadryl)
ANS: C The valproates are first-line drugs for treatment of manic episodes associated with bipolar disorder or resulting from general medical problems. They have a rapid onset and are well tolerated. Lithium takes 7 to 10 days to modify symptoms. Diphenhydramine and amitriptyline have sedative side effects but would not stabilize the mania.
4. A nurse assesses a new patient experiencing a manic episode. Which behavior is most likely to have occurred before hospitalization? a. Watching others closely but avoiding interaction b. Taking frequent rest periods during the day c. Going rapidly from one activity to another d. Remaining in the home for long periods
ANS: C There is increased physical and mental activity exhibited during a manic episode. Moving rapidly from one activity to another is characteristic behavior during a manic episode. The other behaviors mentioned are not consistent with what occurs during a manic episode.
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.
19. To reduce the risk of a lawsuit based on false imprisonment, mental health nurses must give the highest priority to which intervention? a. Educating patients about unit protocols b. Providing adequate treatment during hospitalization c. Selecting the least restrictive treatment environment that will be effective d. Ensuring that patients have probable-cause hearings within 24 hours of admission
ANS: C Treating a patient in the least restrictive environment that will be effective lessens the threat of the patient bringing civil suit for false imprisonment. In the least restrictive environment, the disruption to patient rights is minimized. Providing information about unit rules and providing adequate treatments are of less immediate importance than ensuring the least restrictive alternative. Probable-cause hearings are necessary only in certain cases.
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.
14. A patient says to the nurse, "My family was mean to me when they visited today. They have no right to treat me like that." What is the nurse's best initial response to the patient's concerns? a. "Why do you think they were mean?" b. "Perhaps you overreacted to what they said." c. "How do you feel about your family treating you that way?" d. "Describe what happened when your family visited you today."
ANS: D Before proceeding, the nurse needs to have a better understanding of what happened in the interaction between the patient and family. The correct option seeks that clarification, whereas none of the other options takes that approach.
2. A patient diagnosed with bipolar disorder is admitted involuntarily during a manic phase. Lithium 300 mg PO t.i.d. is prescribed. The patient refuses the morning dose. What are the nurse's best actions? (Select all that apply.) a. Get the prescription changed to an elixir, and administer it in juice. b. Assemble adequate help to force the patient to take the medication. c. Educate the patient about the importance of lithium in stabilizing the mood. d. Allow the patient to refuse the medication, and document the patient's comments. e. Inform the patient that unit privileges are contingent on taking prescribed medications.
ANS: C, D Patients have the right to refuse consent to treatment, including medication administration. The courts have ruled that neither voluntary nor involuntary patients can be forced to take psychotropic medication. Hiding the medication in food or fluids is not ethical. Assembling a show of force implies that forcible administration will occur. Making privileges contingent on medication ingestion is
2. A nurse prepares to lead a psychoeducational group for patients who take anticonvulsants to manage bipolar disorder. The nurse should invite patients who take which drugs? Select all that apply. a. Lithium b. Aripiprazole (Abilify) c. Lamotrigine (Lamictal) d. Gabapentin (Neurontin) e. Carbamazepine (Tegretol)
ANS: C, D, E Lamotrigine, carbamazepine, and gabapentin are anticonvulsants. Lithium is effective in treatment of bipolar disorder, but it is not an anticonvulsant. Aripiprazole is an antipsychotic medication.
1. A student goes to a party the night before a test and then fails the exam. After seeing the score, the student slams a book on the table and says, "I have to work so much and have no time to study. It wouldn't matter anyway because the teacher is unreasonable." The nurse identifies use of which defense mechanisms? (Select all that apply.) a. Denial b. Compensation c. Rationalization d. Projection e. Displacement f. Reaction formation
ANS: C, D, E The student slams down the book, displacing anger, rationalizes (makes excuses), and projects blame onto the teacher. Compensation involves making up for a perceived weakness by emphasizing a desirable trait. Projection refers to blaming others or attributing unacceptable thoughts or behaviors to others. Reaction formation involves doing the opposite of an unacceptable desire.
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.
17. A nurse talks with the caregiver of a combat veteran with severe traumatic brain injury. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Which resource should the nurse suggest? a) Al-Anon b) Pastoral care c) Meals on Wheels d) Multifamily support group
ANS: D A multifamily support group will provide education, support, and socialization. These services support the needs of this caregiver. Pastoral care will offer support but not education and socialization. There is no indication of substance abuse or problems with meal preparation.
21. A nurse should schedule a weekly complete blood cell count (CBC) for a patient beginning therapy with which antimanic drug? a. Lithium b. Valproate (Depakote) c. Quetiapine (Seroquel) d. Carbamazepine (Tegretol)
ANS: D Agranulocytosis is known to be an occasional but potentially dangerous adverse effect of carbamazepine therapy, hence the need for regular CBCs. The other drugs have a lower risk of causing this effect.
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.
7. A Hispanic parent reports, "An old woman gave my baby the evil eye." After it's determined that the infant is physically healthy. What intervention will be most culturally competent in resolving the parent's concern? a. Assuring the parent that the baby is healthy and needs no treatment b. Explaining that the evil eye is a superstition and not a cause of illness c. Encouraging the parent to immerse the baby in a cool water bath for 5 days d. Offering to arrange a healer to see the child
ANS: D An individual who believes in mal ojo (evil eye) will also believe that Western medicine is ineffective to treat it. This person will believe that because the illness has an unnatural cause, treatment is best conducted by a native healer who can remove the spell. The parent would not view offering no treatment or casting doubt on evil eye as a superstition as helpful, making these options culturally insensitive. A cool water bath could not address the expressed concerns.
20. A patient diagnosed with bipolar disorder has stabilized and is being discharged from the hospital. The patient will live independently at home but lacks social skills and transportation. Which referral would be most appropriate? a. A group home b. A self-help group c. A day treatment program d. Assertive community treatment (ACT)
ANS: D Assertive community treatment (ACT) provides intensive supervision, which includes assistance with medications and transportation that would support the goal of minimizing future hospitalizations. A group home is unnecessary, because the patient will reside at home. A day treatment program would provide a therapeutic program directed toward symptoms, but the patient's symptoms have stabilized so this service is not indicated. A self-help group would not provide the intensity of service this patient needs.
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.
23. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my parents, but you can't tell them." Select the nurse's initial response. a. "You're right. Federal law requires me to keep information private." b. "Those kinds of threats will make your hospitalization last much longer." c. "You really should share this thought with your psychiatrist." d. "I am required to talk to the treatment team about your threats."
ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances, because a team approach to delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the patient's parents of the risk for harm. Considering this information, none of the other options is accurate.
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.
17. What should be the initial assessment in the rational-emotive therapy process implemented to help the chronically depressed patient? a. Presence of developmental tasks and progress b. The management of environmental stressors c. The childhood influences on the patient's emotional state d. The presence of irrational beliefs related to painful feelings
ANS: D Cognitive therapists believe that irrational beliefs or automatic thoughts cause self-defeating behaviors to be maintained. Individuals can challenge their self-defeating behaviors once they identify irrational beliefs and see their connection to painful feelings. The other options reflect interventions that might occur later.
20. How many violations of Medicare and Medicaid guidelines are evident in this documentation? Patient assaulted nurse in hall at 1730. Staff provided verbal intervention, but patient continued to strike out. Patient placed in seclusion at 1745. Observation instituted at hourly intervals. Order received from physician at 1930. Patient sleeping soundly at 2100. Patient released from seclusion at 2230 and returned to own room. a. Two b. Three c. Four d. Five
ANS: D Constant observation of a secluded individual is necessary, with attention given at frequent intervals for safety and comfort interventions. No mention is made of providing fluids or bathroom privileges. Seclusion requires a written order posted within 1 hour. Seclusion must be terminated when patient behavior permits. If the patient is calm enough to sleep, the need for seclusion should be re-evaluated.
1. A nurse begins work at an agency that provides care to members of a minority ethnic population. What intervention should the nurse implement to demonstrate cultural competence? a. Identifying popularly held culture-bound issues b. Implementing scientifically proven interventions c. Correcting inferior health practices of the population d. Exploring commonly held beliefs and values of the population
ANS: D Cultural competence is dependent on understanding the beliefs and values of members of a different culture. A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture. The other options have little to do with cultural competence or represent only a portion of the answer.
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.
14. After a patient's first group session, the nurse asks, "How was the experience of participating in group for you?" Which communication technique is the nurse using? a. Summarizing b. Seeking clarification c. Making observations d. Encouraging evaluation
ANS: D Distinguishing among the techniques listed shows that the nurse is encouraging evaluation when asking a patient to make a judgment about the experience. This opens the door to further exploration of thoughts and feelings.
Which account of history and symptoms is most consistent with dysthymia? a. Depressed mood for 2 weeks; anhedonia; feelings of worthlessness. b. Delusions of guilt and poverty; weight loss; agitation beginning 3 weeks ago. c. Depressed mood for 3 months; suicidal ruminations; hypersomnia; sullen affect. d. Depressed for 3 years; poor concentration; anhedonia; low-self esteem; indecision.
ANS: D Dysthymia is a depressive disorder marked by chronicity. The depression must have been present more than 50% of the time for at least 2 years. The other options describe major depression and psychotic depression.
24. Referral to a psychiatric extended-care facility would be most appropriate for which of the following patients? a. An adult with generalized anxiety disorder b. A severely depressed 70-year-old retiree c. A patient with personality disorder who frequently self-mutilates d. A severely ill person with schizophrenia who is regressed and withdrawn
ANS: D Extended care often serves those with severe and persistent mental illness and those with a combination of psychiatric and medical illnesses. The patient demonstrating the signs and symptoms described in the correct option is at risk for developing psychotic behaviors that increases the risk for self and other directed harm. Patients with anxiety disorders can be referred to outpatient services. Severely depressed patients would need more intensive care, as would a self-mutilating individual.
1. Which assessment finding would the nurse document as subjective evidence of anorexia nervosa? a. Presence of lanugo on body b. Bradycardia notes upon regular assessment c. 25-lb weight loss over 3-month period d. Patient states fear of gaining weight
ANS: D Fear of weight gain is a subjective symptom, because it is voiced by the patient. The distracters are objective signs.
13. A 14-year-old is sent to a residential program after arrests for truancy and assault. At the program, the teen refused to participate in scheduled activities and pushed a staff member, causing a fall. Which statement made by the nurse demonstrates an effective strategy to manage the client effectively? a. "I've enrolled you in the unit's social skills training group to help you interact with others better." b. "What will it take to get you to obey unit rules?" c. "If you don't want to go to movie night you don't have too." d. "There is a loss of privileges following any refusal to comply with unit rules."
ANS: D Firm limits are necessary to ensure physical safety and emotional security. Limit-setting will also protect other patients from the teen's thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.
3. A patient asks, "Why is it important to uncover memories and conflicts hidden in the unconscious?" According to Freud, what effect does this intervention support? a. Resolves developmental issues, fears, and crises. b. Allows an individual control over the id and superego. c. Suppress painful feelings and increase rational thinking. d. Provides insight into behavior and allow meaningful change to occur.
ANS: D Freud believed that uncovering unconscious material generates an understanding of behavior that enables individuals to make choices about behavior and thus improve mental health. It will not, however, automatically resolve issues, give the patient control over id and superego strivings, or result in rational thinking.
5. A patient diagnosed with bipolar I disorder says, "I will lead the next group about medications. I have studied all the effects and problems with drugs on the Internet, so I can answer patients' questions." How should the nurse document this finding? a. Flight of ideas b. Distractibility c. Limit-testing d. Grandiosity
ANS: D Grandiosity is reflected when the individual makes statements that show an inflated sense of self-worth. Flight of ideas refers to rapidly shifting topics of conversation. Limit-testing refers to attempting to override the structure of the milieu. Distractibility refers to inability to maintain concentration when environmental stimuli shift.
18. Which comment made by a member of a support group, best contributes to group cohesiveness and effectiveness? a. "Talking about my problems helps me think of ways to solve them. Let me explain them to everyone." b."We aren't making progress because our group leader has as many problems as we do." c. "No one in this group wants to hear anything else about your financial problems." d. "We started out talking about guilt, but we wandered off from that subject."
ANS: D Group leaders must recognize and manage a group process and content. Cohesiveness helps the group achieve its goals. The speaker has made an observation of the group process. Distracting, dominant, or hostile comments distract from the curative factor of universality.
8. A cognitively impaired psychiatric patient has been a court appointed guardian. What the nurse is appropriate in seeking the opinion of the guardian regarding what matter? a. The patient's need for a winter coat b. Accompanying the patient on an outing off of facility grounds c. Addressing the patient's financial issues d. TA change in needed treatment
ANS: D Guardians make decisions on behalf of the patient related to their well-being. Being consulted about treatment planning is an appropriate area for a guardian's input. None of the other options are directly associated with the role of a guardian. D
12. Which individual would be the most likely candidate to require at court appointed guardian? a. A patient diagnosed with panic attacks b. A patient who frequently refuses medication c. A patient with frequent admissions for drug abuse d. A patient diagnosed with chronic, paranoid schizophrenia
ANS: D Guardians or conservators are appointed by the courts to manage the affairs of mentally ill individuals found to be incompetent and unable to manage their own affairs appropriately. A patient diagnosed with chronic, paranoid schizophrenia would be in need of a conservator or guardian, whereas the other individuals would more likely be judged competent since their diagnoses are not necessarily chronic in nature or as likely to impair rational thinking.
1. Which factor presents the most imminent risk for the development of a childhood psychiatric disorder? a.Having an uncle diagnosed with schizophrenia b. Living in a low-income family c. Being the oldest child in a family d. Living with an alcoholic parent
ANS: D Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Neither being in a low-income family nor being the oldest child are considered psychosocial adversity situations. While having an extended family history of schizophrenia presents a risk, the negative childhood events associated with having an alcoholic parent present a higher level of risk.
13. A family expresses helplessness related to dealing with a mentally ill member's odd behaviors, mood swings, and argumentativeness. Which nursing intervention for the family should be included into the careplan to help reduce interpersonal stress by learning new coping skills? a. Express sympathy regularly. b. Involve local social services. c. Explain symptoms of relapse. d. Role-play problem situations.
ANS: D Helping a family learn to set limits and deal with difficult behaviors can often be accomplished by using role-playing situations, which give family members the opportunity to try new, more effective approaches. The other options would not provide learning opportunities.
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.
6. A patient reports an inability to sleep because of too much noise and light, even though the environment is quiet with soft lighting. The nurse knows such reports support dysfunction of which organ? a. Basal ganglia b. Pituitary gland c. Substantia nigra d. Hypothalamus
ANS: D Hypothalamic areas mediate autonomic activities and wakefulness (via noradrenaline, histamine, and orexin), and which also interconnect with pineal gland-releasing melatonin-mediated circadian "sleep-switch" functions to project to frontal cortex. The other structures are not involved in the sleep function.
1. When a nurse administers medication that focuses on the management of Parkinson disease, what is the focus of the associated evaluation? a. Spinal nerve function b. The central nervous system c. The sympathetic nervous system d. The expected effects of dopamine
ANS: D In Parkinson disease (PD), dopamine is reduced by death of dopamine releasing cells in the substantia nigra. Without the excitatory effect of dopamine to the striatum, more pallidal firing reduces thalamic activity. Cortical activating effects are reduced, with decline in initiating and executing motor activity, causing bradykinesia, and disinhibition of muscular control, causing resting tremor, rigidity, and loss of postural reflexes. Treatment efforts in PD are directed at resupplying dopamine to the CNS via L-DOPA, or providing dopamine antagonists. This drug therapy does not affect spinal nerve function or function associated with the central or sympathetic nervous systems.
2. A nurse, preparing a community presentation, should include what information concerning the most accurate characterization of treatment of the mentally ill prior to the Period of Enlightenment? a. Large public asylums provided custodial care. b. Care for the mentally ill was more compassionate. c. Care focused on reducing stress and meeting basic human needs. d. Patients were often displayed for public amusement.
ANS: D In the 1700s it was common practice for caretakers to display mentally ill patients for the amusement of the paying public. The creation of large asylums took place during the Period of Enlightenment. Mental illness was first studied during the Period of Scientific Study. Dealing with stress and meeting basic needs are concerns of the modern era.
12. The patient is tense, hypervigilant, and reports, "My heart is racing." The nurse understands that the client is experiencing what sympathetic nervous system reaction? a. Hypothalamic-pituitary-adrenal axis b. Split-brain syndrome c. Blood brain barrier d. Fight or flight
ANS: D In the fight or flight response is associated with the sympathetic stimulation and causes increased heart rate and blood pressure and other symptoms of anxiety. None of the other options are associated with sympathetic nervous system stimulation.
9. A nurse plans care for a client who in the recoil phase of trauma recovery. What assessment question addresses a common focus of this phase? a. "Are you having nightmares about the trauma you experienced?" b. "Does it feel like the abuse happen to someone else?" c. "Is there anyone you blame for putting you in that situation?" d. "What are your fantasies about getting revenge on your abuser?"
ANS: D In the recoil stage, emotional stress is high as the individual strives to come to terms with what has happened. Fantasies of revenge for the crime are natural during this stage. The initial reaction to a single-event trauma usually lasts a few minutes to a few days. Occasionally, the victim's reaction might include dissociative symptoms (amnesia, depersonalization, numbing, detachment), intrusive memories (nightmares, flashbacks), and severe anxiety. Disorganization may be a reaction in the impact stage. The beginning of this phase includes making sense of what happened and why ("Why me?"); attributing blame to self, others, or
20. A nurse could anticipate that the treatment plan for a patient experiencing memory difficulties might include medications designed to bring about what outcome? a. Inhibit GABA b. Increase dopamine at receptor sites c. Decrease dopamine at receptor sites d. Prevent destruction of acetylcholine
ANS: D Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA is known to affect anxiety level rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson disease rather than improving memory.
6. The nurse can expect the parent of a child with mal ojo (evil eye) to believe that the effects of the spell can be broken after what intervention? a. Focusing on the parents rather than the child b. Arranging to feed the child warm foods c. Looking deeply into the child's eyes d. Consulting by a root doctor or native healer
ANS: D Individuals who believe in culture-bound illnesses usually also believe that the cure for the illness is found in treatment by a native healer or roots doctor. None of the other options are effective since the parent would not believe that any of the other options are effective.
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.
12. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our child sometimes acts so strangely that we don't invite friends to the house. Sometimes we don't get any sleep. We quit taking vacations." Which nursing diagnosis applies? a. Impaired parenting b. Dysfunctional grieving c. Impaired social interaction d.Interrupted family processes
ANS: D Interrupted family processes are evident in the face of disruptions in family functioning as a result of having a mentally ill member. Data support the possibility of this diagnosis. Data are insufficient to consider the other diagnoses.
14. School nurses should be particularly vigilant for signs of eating disorders related to what timeline? a. Fourth-graders who have never attended another school. b. Rebellious, aggressive girls at any age. c. Pre and post holidays and prior to summer break. d. At transitions between elementary, middle, and high school.
ANS: D Junior high and high school students are at particular risk for eating disorders, based on our culture's emphasis on thinness and the adolescent's need for peer approval. Stress makes the adolescent more vulnerable. Times of particular stress are moving from one school to another—thus, the need for vigilance on the part of the school nurse. Risk is lower in the other options since stress is not generally associated with these characteristics.
A clinic nurse assesses a new Latino patient who repeatedly complains of feeling nervous and having headaches. No organic pathology is present. The symptoms began about 3 years ago when the patient's parent died. Select the nurse's best first action. a. Explore the patient's grief. b. Encourage the patient to take frequent rest periods. c. Reassure the patient that these feelings are normal. d. Screen for additional signs and symptoms of depression.
ANS: D Latino patients often do not express depression as being related to their mood; rather, they present vague somatic symptoms. Nurses often have good understanding of cultural differences. The nurse should first screen for other signs and symptoms of depression. The patient's feelings are not normal when considered from a cultural viewpoint. Reassuring the patient that the feelings are normal would be nontherapeutic. Exploring grief may come later. Frequent rest periods would isolate the patient who actually needs support.
3. A positive outcome achieved after attending a special-problems group is evidenced by which patient statement? a. "You're a great group leader and kept things moving smoothly." b. "This experience wasn't as bad as I thought it would be." c. "I rely on the group to help me make decisions." d. "I learned how my anger affects other people."
ANS: D Learning more about one's behavior and its effects on others is an appropriate outcome for group therapy. The other options do not reflect patient growth.
11. A medication teaching plan for a patient receiving lithium should include: a. directions to eat one or two bananas daily. b. dietary teaching to limit daily sodium intake. c. the need to restrict daily fluid intake to 1000 ml. d. the importance of laboratory testing to monitor the lithium level.
ANS: D Maintaining serum lithium levels within 0.6 and 1.2 mEq/L is vital to symptom control. The patient must be made aware that frequent monitoring will foster symptom control and prevent toxicity. The other options are inappropriate in a teaching plan.
11. The nurse tells a patient, "I noticed that you frowned when we discussed your relationship with your family." Which communication technique is the nurse using? a. Clarifying b. Interpreting c. Giving information d. Making observations
ANS: D Making observations is defined as commenting on what is seen or heard to encourage discussion. The nurse's statement cannot be interpreted as using any of the other techniques listed.
16. A woman demonstrating characteristics of "battered woman syndrome" should be asked which assessment question to identify a comorbid psychological condition? a. "Have you ever been sexually abused?" b. "Have you ever been diagnosed with major depression?" c. "Would you say you experience anxiety on a regular basis?" d. "Are you aware of the condition known as posttraumatic stress disorder (PTSD)?"
ANS: D Many of the symptoms of battered woman syndrome correspond to the symptoms of PTSD; however, battered woman syndrome has additional symptoms not delineated as part of PTSD (e.g., depression, low self-esteem, self-blame, fatalism). It is not related to the other options.
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.
17. The spouse of a patient diagnosed with bipolar disorder tells the nurse, "Every time my partner recovers from a manic episode, depression follows soon. It's very discouraging." The nurse's reply should include what information? a. As the partner ages, rapid cycling will decrease. b. Combining lithium with haloperidol (Haldol) might prevent rapid cycling. c. Depression associated with bipolar disorder is usually time-limited, so treatment is not indicated. d. Recent addition of olanzapine (Zyprexa) to this patient's drug regime can be helpful as a mood stabilizer.
ANS: D Olanzapine, an atypical antipsychotic, has proven effective in controlling mania and acting as a mood stabilizer to reduce depression following treatment for acute mania. The other statements are incorrect or irrelevant.
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.
10. A soldier returned home last year after deployment to a war zone. The soldier's spouse reports, "We had planned to start a family right away, but now he won't talk about it. He won't even look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a) "PTSD often changes a person's sexual functioning." b) "I encourage you to continue to participate in social activities where children are present." c) "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d) "PTSD often strains relationships. Here are some community resources for help."
ANS: D PTSD precipitates changes that often lead to divorce. It's important to provide support to both the veteran and spouse. Confrontation will not be effective. While it's important to provide information, ongoing support will be more effective.
1. Paraphilia is defined as involving what behavior? a. Engaging in homosexual sexual behaviors b. Having difficulty maintaining a sexual arousal c. Feeling discomfort with one's biological sexual gender d. Experiencing climax only when sexual behavior is illegal
ANS: D Paraphilias are conditions in which the sexual instinct is expressed in ways that are socially prohibited or unacceptable or are biologically undesirable. The distracters characterize other sexual behaviors.
Which nursing intervention is most likely to result in heightened self-awareness for a patient diagnosed with a personality disorder in the dramatic-erratic cluster? a. Setting firm limits on behavior b. Providing clear expectations for acceptable behavior c. Using confrontational approaches to reduce self-mutilation d. Encouraging the patient to keep a daily journal to be shared with the nurse
ANS: D Patients can be helped to understand themselves and their feelings by keeping a journal. Sharing the journal with the nurse fosters greater understanding and a sense of autonomy and responsibility. The other options do not heighten self-awareness.
7. An adult diagnosed with schizophrenia is being discharged from a state mental hospital after 20 years of institutionalization. What intervention should the nurse include in discharge planning to best manage the relapse of symptoms? a. Discuss methods to assist in the transition from hospitalization to community. b. Encourage the client to use community support services. c. Evaluate the client's ability to effectively self-administer antipsychotic medications as prescribed. d. Educate the client and family to the likely need for crisis or emergency psychiatric interventions from time to time.
ANS: D Patients with serious mental illness are rarely considered cured at the time of hospital discharge. Decompensation is likely from time to time, even when good community support is provided. While the remaining options are appropriate, none will affect relapse manage more than an understanding that relapse care will likely be necessary.
1. A newly licensed asks a nursing recruiter for a description of nursing practice in the psychiatric setting. What is the nurse recruiter's best response? a. "The nurse primarily serves in a supportive role to members of the health care delivery team." b. "The multidisciplinary approach eliminates the need to clearly define the responsibilities of nursing in such a setting." c. "Nursing actions are identified by the institution that distinguishes nursing from other mental health professions." d. "Nursing offers unique contributions to the psychotherapeutic management of psychiatric patients."
ANS: D Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Neither the facility nor the multidisciplinary team define the professional responsibilities of its members but rather utilizes their unique skills to provide holistic care. Ideally, all team members support each other and have functions within the team.
A patient with depression paces and pulls at clothing constantly. The patient cannot sit for longer than 5 minutes, even at meals. How should the nurse document this behavior? a. Perseveration b. Hypomanic activity c. Catatonic excitement d. Psychomotor agitation
ANS: D Psychomotor agitation is marked by increased, purposeless, repetitive motor activity, often performed with a sense of urgency. The description of the patient's behavior is consistent with this definition, rather than any of the other options.
12. What statement made by a client accused of sexual abuse is characteristic of the primary motivation for most rapes? a. "I was so nervous I just couldn't stop myself." b. "I know a lot of men who act the same way." c. "She wanted the sex, she just didn't want to say so." d. "She is such a tease; I needed to teach her a lesson."
ANS: D Rape is not a crime of sex, but rather a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.
9. A patient tells the nurse, "The reason I use drugs is because everybody nags me to do things that don't interest me." The patient shows use of which defense mechanism? a. Sublimation b. Introjection c. Identification d. Rationalization
ANS: D Rationalization is an attempt to prove that one's behaviors or feelings are justifiable and involves making justifications of feelings or behaviors. Sublimation channels instinctual drives into acceptable channels. The patient is not modeling after another person or incorporating another's values.
10. A patient is mute, curled in a fetal position, and incontinent of urine. The patient eats small amounts only if spoon-fed. The nurse assesses this behavior as most indicative of what defense mechanism? a. Displacement b. Compensation c. Conversion d. Regression
ANS: D Regression is defined as the return to an earlier, more comfortable developmental state—in this case, infancy. Displacement involves discharging feelings to an object that is less threatening. Compensation refers to covering a weakness by overemphasizing a desirable trait. Conversion refers to the unconscious expression of conflict symbolically through physical symptoms.
16. A nurse is assigned to an outreach program on a Native-American reservation. Which tenet should the nurse consider when communicating with the consumers with an ecologic worldview? a. Silence is considered a social error. b. Touching is an accepted part of conversation. c. Important topics are always preceded by polite social conversation. d. Rules regarding roles and status are important and must be observed.
ANS: D Relationships are based on the idea that the Supreme Being is present in each person and that all persons must be valued and treated with dignity. This is particularly true of treatment received by tribal elders, healers, and others perceived to be in positions of importance. The other options are not consistent with the ecologic worldview.
18. A patient who abuses heroin says, "I have willpower to manage my life in other areas, but I feel helpless to control my craving for heroin." The nurse's response should be based on research findings suggesting that addictive behavior is related to changes in what area of the brain? a. Cortisol secretion b. The substantia nigra c. Mitochondrial DNA d. The nucleus accumbens
ANS: D Research has implicated the nucleus accumbens as having a role in addictive behaviors. The substantia nigra is concerned with dopamine production. Excessive cortisol secretion has its primary effect on the hippocampus. Mitochondrial DNA mutation has not been implicated in addiction risk.
19. Which option describes an action that is common among healthy families? a. One parent takes care of the children. The other parent earns income and maintains the home. b. A family has strict boundaries that require members to address problems inside the family. c. A couple requires their adolescent children to attend church services three times a week. d. A couple renews their marital relationship after their children become adults.
ANS: D Revamping the marital relationship after children move out of the family of origin indicates that the family is moving through its stages of development. Strict family boundaries or roles interfere with flexibility and the use of outside resources. Adolescents should have some input into deciding their activities.
15. The child most likely to receive risperidone to manage symptoms is one diagnosed with what mental health disorder? a. Attention-deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Anxiety d. Autism
ANS: D Risperidone is useful for relieving irritability and labile affect demonstrated by some autistic children. It is not indicated in any of the other disorders.
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.
21. An adult in the emergency department has wrist slashes, suggesting self-mutilation. The patient's history reveals alcohol and drug abuse, binge eating, and unstable interpersonal relationships. Which history should the nurse suspect? a. Rape trauma b. Partner abuse c. Serial ritual abuse d. Childhood sexual abuse
ANS: D Self-mutilation; alcohol and drug abuse; bulimia; and unstable, unsatisfactory relationships are frequently seen in patients who were sexually abused as children and have repressed the trauma. These behaviors are not as closely aligned with any of the distracters.
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.
2. The partner of a psychiatric patient says, "This mental illness should not have happened. I tried to teach the importance of professing faith in God and getting converts, but my partner rejected them. Those practices keep me well. It's the only way to live." The nurse can assess that the spouse is demonstrating what form of religiosity? a. Atheism b. Humanism c. Agnosticism d. Sick religiosity
ANS: D Sick religiosity is marked by a lack of openness to other possibilities, a sense of exclusiveness, and absolutism. The scenario does not give evidence of any of the other options.
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.
12. During a support group meeting focusing on strategies to manage symptoms, a patient asks the nurse leader how to deal with angry outbursts from a supervisor. What response technique should the nurse discuss? a. Answer the question, and then move on to another topic. b. Offer to answer the question privately after the group session. c. Inform the patient that only illness-related problems can be discussed in the group. d. Matter-of-factly explain that the topic being discussed is the importance of medication.
ANS: D Some patients ask distracting questions, seeking answers directly from the leader. The nurse leader preserves the group process by returning the focus to the group and the topic being discussed. Only the correct option accomplishes this.
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.
16. A patient states, "I'm tired of all these therapy sessions. It's just too much for me." Using supportive confrontation, how should the nurse reply? a. "It will get better if you just keep trying." b. "You are doing fine. Don't be so hard on yourself." c. "Tell me more about how the therapy sessions are too much." d. "I know you find this difficult, but I believe you can get through it."
ANS: D Supportive confrontation is a technique in which the nurse acknowledges the difficulty in changing, but pushes for action. The other options clarify or give reassurance.
7. A patient tells the nurse, "When I get out, I'm going to get even with a lot of people." With respect to the nurse's duty to warn, what priority action should the nurse take? a. Discuss the consequences of such actions with the client. b. Notify local law enforcement officials of the threat. c. Warn close relatives and significant other as required by law. d. Document and discuss the threat with the clinical team.
ANS: D The Tarasoff ruling specifies that a specific threat to a readily identifiable person or persons must be made. In this situation, the threat is nonspecific. The prudent action is to document and discuss with the clinical team to determine the need for providing a warning to third parties and to notify the police. While discussing the consequences of acting on the threat is not inappropriate, it is not the priority intervention required.
4. A nurse prepares to assess a newly hospitalized patient who moved to the United States 6 months ago from Somalia. What issue should the nurse focus upon initially? a. If the patient's immunizations are current b. The patient's religious preferences c. The patient's specific ethnic group d. Whether there is a need for an interpreter
ANS: D The assessment depends on communication. The nurse should first determine whether or not an interpreter is needed. The other information can be subsequently assessed when communication is effective.
9. Dysfunction in which structure should lead the nurse to consider institution of fall precautions? a. Wernicke area b. Hippocampus c. Amygdala d. Cerebellum
ANS: D The cerebellum is responsible for the maintenance of equilibrium. When equilibrium is impaired, fall prevention becomes a priority. Problems in Wernicke area are associated with impaired comprehension of the spoken word. Problems with the hippocampus or amygdala are associated with impaired memory formation.
19. During an interdisciplinary team meeting, a nurse shares that, "The patient's psychological distress seems to result from automatic thoughts that cause self-defeating behaviors." The nurse is conceptualizing the patient's problem from the viewpoint of which model? a. Interpersonal b. Psychoanalytic c. Stress-adaptation d. Cognitive-behavioral
ANS: D The cognitive-behavioral model recognizes the role of automatic thoughts (irrational beliefs) in promulgating self-defeating behaviors. The information given in the scenario does not reflect conceptualization using any of the other models.
9. Which nursing intervention is associated with a shift in the psychiatric nursing focus during the community mental health period of the 1960s? a. De-emphasizing the high numbers of people seeking treatment b. Making substance abuse the primary focus of care c. Focusing services on persons with serious mental illness d. Assessing the client's potential for improvement
ANS: D The community mental health movement brought with it a broadening of areas of concern to the psychiatric nurse. It became acceptable, even desirable, for psychiatric nurses to focus on what was called the worried well, as opposed to providing care for acutely ill psychotic individuals. Neither disillusionment with the numbers seeking treatment nor providing more services to those with severe mental illness occurred.
5. A patient diagnosed with split-brain syndrome has damage to which structure of the brain? a. Amygdala b. Hippocampus c. Pyramidal tract d. Corpus callosum
ANS: D The corpus callosum connects the two brain hemispheres. When this communication pathway is severed, split-brain syndrome develops. None of the other structures is implicated in this disorder.
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.
8. Which information about a patient diagnosed with bulimia nervosa should the nurse document as subjective data? a. Scarred fingers b. Sores around mouth c. Loss of tooth enamel d. Feeling out of control
ANS: D The distracters represent objective data, whereas the correct answer reflects feelings the patient has revealed.
8. The parent of an 8-year-old says, "My child is in constant motion, talking all the time but is out of bed every morning before I am and into trouble." This description supports which mental health diagnosis? a. Bipolar disorder (BPD) b. Disruptive mood dysregulation disorder (DMDD) c. Oppositional defiant disorder (ODD) d. Attention-deficit hyperactivity disorder (ADHD)
ANS: D The excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest the other possible choices. oppositional defiant disorder (ODD) in children and adolescents is defined as a pattern of angry/irritable mood symptoms. Bipolar disorder (BPD) in children differs from the adult type in that irritability is a more prominent symptom, and there are often high rates of co-occurring attention problems and anxiety. The diagnosis of disruptive mood dysregulation disorder (DMDD) was established in DSM-5 to help account for youngsters who are very irritable or angry much of the day, nearly every day, and who have severe recurrent temper outbursts.
14. The emergency department triage nurse should assign to initially care for a female client who has been raped? a. Social worker with good communication skills b. Male nursing assistant who is tall and caring c. Nurse who is efficient and attentive to detail d. Soft-spoken and empathetic nurse
ANS: D The female rape victim might be frightened of or reluctant to interact with men, so a female nurse is preferable. The patient should not be made to feel hurried or pressured, but needs to feel nurtured and understood. A social worker is not necessarily trained to address the physical or emotional issues created by a rape.
11. A patient chronically demonstrates aggression. Neuroimaging studies will most likely show dysfunction in which part of the brain? a. Temporal lobe b. Cerebellum c. Brain stem d. Frontal lobe
ANS: D The frontal lobe modulates information streams from deeper brain areas, such as the ascending arousal system, impulses which drive hunger, aggression, and sexual arousal. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brain stem regulates internal organs.
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.
Characteristic behaviors a nurse would expect when working with a patient diagnosed with narcissistic personality disorder are: a. preoccupied with details; perfectionism. b. socially isolated; odd, eccentric behavior. c. dramatic expression; easily influenced by others. d. grandiosity; sense of entitlement; lack of empathy
ANS: D The individual with narcissistic personality disorder displays grandiosity about self-importance and achievements, does not empathize or understand the feelings of others, exhibits a sense of entitlement, and expects special treatment. The other options reflect characteristics of histrionic personality disorder, obsessive-compulsive personality disorder, and schizotypal personality disorder
20. When a Mexican-American woman and female nurse interact, the patient often holds the nurse's hand or links arms with the nurse. Which analysis of this behavior demonstrates the nurse's understanding of this behavior? a. The patient is using touch to make the nurse uncomfortable and manipulate the relationship based on that factor. b. An energy field disturbance has occurred. Touch rebalances the energy between the patient and nurse. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The patient is accustomed to and comfortable with touch, as are members of many Hispanic cultures.
ANS: D The most likely answer is that the patient's behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are much less likely when considering the Hispanic, cultural influence.
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.
20. During an interview with a depressed patient, the nurse sits with folded arms and fidgets when long silences occur. When the patient expresses hopelessness about getting better, the nurse replies, "You will feel better when your medication takes effect." This interaction demonstrates what characteristic regarding therapeutic response by the nurse? a. Therapeutic use of limit-setting b. Minimally therapeutic but effective c. Therapeutic use of self d. Nontherapeutic and ineffective
ANS: D The nurse is demonstrating a closed posture, suggesting lack of interest in the interaction. Fidgeting suggests boredom or lack of comfort during the interaction. The quoted response minimizes the patient's problem and sounds short. Cumulatively, these indicate that the nurse's behaviors are nontherapeutic and ineffective.
10. In the waiting room a 5-year-old child diagnosed with attention-deficit hyperactivity disorder (ADHD) bounces out of a chair, runs over to another child, and slaps the other child. What action implemented by the nurse would be most effective in therapeutically managing the situation? a. Direct the aggressive child to stop immediately. b. Call for emergency assistance from other staff. c. Instruct the parents to take the child home. d. Take the child to another waiting area.
ANS: D The nurse should manage the milieu with structure and limit-setting. Removing the aggressive child to another waiting area is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency situation. Intervention is needed rather than sending the child away.
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.
8. A soldier who served in a combat zone tells the nurse, "I saw a child get blown up over 2 years ago, but even now when I see something red, the visions race back to my mind and I smell burnt flesh." How should the nurse document this experience? a) Thought intrusion b) Repetitive dreams c) Hallucinations d) Flashbacks
ANS: D The soldier describes an event while awake related to reexperiencing the trauma. The description applies to flashbacks, which are common in PTSD. The statement is not associated with the remaining options.
3. For 2 weeks a patient has taken lithium (Lithane) and risperidone (Risperdal) daily for mania. The patient now reports diarrhea, vomiting, and blurred vision. The nurse observes a coarse hand tremor. Select the nurse's priority action. a. Administer a PRN dose of benztropine (Cogentin) to relieve extrapyramidal symptoms (EPSEs). b. Hold the next dose of risperidone to prevent further drug-drug interaction. c. Reassure the patient that these side effects will decrease with time. d. Notify the prescribing physician immediately.
ANS: D The symptoms the patient is experiencing are consistent with a serum lithium level above the therapeutic level. The nurse should withhold the next dose, arrange for a stat serum lithium level determination, and notify the health care provider. Risperidone can be continued because this is not a drug-drug interaction problem. Administration of benztropine is inappropriate because these are not EPSE symptoms. Reassurance would be appropriate, but the patient should not be told that these symptoms will decrease with time and continued dosing.
2. A community health nurse visits an older adult whose spouse died 6 months ago and notes several vodka bottles are in the trash. The person says, "I get lonely and drink a little to help me forget." What is the nurse's most therapeutic intervention? a. Teach the person about alcoholism, and suggest other coping strategies. b. Request a mental health consultation to assess for alcohol dependency. c. Advise the person not to drink alone, because the risks for injury increase. d. Arrange for the person to attend an Alcoholics Anonymous (AA) meeting for older adults.
ANS: D This patient needs help with alcohol abuse as well as social involvement. The AA meeting for older adults will provide an opportunity for peer bonding and reminiscing as well as strategies for coping with stress without abusing alcohol. The other options are unnecessary or ineffective.
5. The patient's parent asks the nurse, "Why do you want to do a family assessment? My child is the patient, not the rest of us." What response best addresses the parent's concern? a. "Family dysfunction might have caused the mental illness." b. "Family members provide more accurate information than the patient." c. "Family assessment is part of the protocol for care of all patients with mental illness." d. "Every family member's perception of events is different and adds to the total picture."
ANS: D This response helps the family understand that the opinions of each will be valued. It allows the nurse to assess individual coping and prepares the family for the experience of working together to set goals and solve problems. The other responses are either incorrect or evasive.
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.
7. A patient with rapid-cycling bipolar disorder is not responding to lithium therapy. At the next multidisciplinary team meeting, the nurse should point out that many rapid-cycling patients have been effectively treated using: a. sertraline (Zoloft). b. phenytoin (Dilantin). c. benztropine (Cogentin). d. divalproex (Depakote).
ANS: D Valproates (like divalproex) are considered first-line agents in the treatment of mania. Valproates are especially effective in the treatment of rapid-cycling bipolar disorders. None of the other drugs mentioned are indicated for treatment of manic states.
21. While a member of a group shares painful feelings of guilt, another member begins humming and tapping the side of the chair. Select the leader's best initial statement to best manage the disruptive patient. a. To the speaking patient, "Please realize that not everyone is comfortable with what you are sharing." b. To the entire group, "Humming and tapping can't be tolerated. It is disruptive to our group." c. To the entire group, "Please leave the group now if you can't show empathy for the speaker." d. To the disruptive member, "You seem uncomfortable with our discussion."
ANS: D While the leader must help group members show respect for each other, identifying the possible feelings of the disruptive or hostile person addresses the process in the group and is the initial action required. It will invite self-expression in a more constructive way or extinguish the behavior. If the disruption continues, the leader may need to confront the behavior or excuse the disruptive person.
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.
2. A community mental health nurse works in a mental health services system that is undergoing change to become a seamless system. To promote integrity of the new system, the nurse should focus on: (Select all that apply.) a. psychopathology. b. symptom stabilization. c. medication management. d. patient and family psychoeducation. e. patient reintegration into the community. f. holistic issues relating to patient care.
ANS: D, E, F A seamless system of mental health services will require new conceptualizations. Nurses will need to focus more on recovery and reintegration than on symptom stabilization and more on holistic issues such as finances and housing than on medication management. Consumers and family members will also need to be provided with extensive psychoeducation.
2. After being informed of a diagnosis of lung cancer, a patient says in a cheerful voice, "I feel fine. I will do some reading online about it. Right now, I want to take a nap." The nurse assesses the use of which defense mechanisms? (Select all that apply.) a. Repression b. Undoing c. Introjection d. Reaction formation e. Intellectualization f. Suppression
ANS: D, E, F The cheerful voice is probably the result of reaction formation. The wish to read more about the diagnosis reflects intellectualization. Taking a nap is suppression and allows the patient to avoid having to think about the problem. Repression results in unconscious forgetting. Undoing involves doing something to make up for an unacceptable act. Introjection is incorporating values and attitudes of others as if they were one's own.
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.
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.
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 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 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.
Nortriptyline was prescribed for a 68-year-old patient diagnosed with depression and insomnia. What assessment question should the nurse ask to determine the effectiveness of nortriptyline? a. "Are you having regular bowel movements?" b. "Are you no longer experiencing insomnia?" c. "Have you been successful with weight loss?" d. "Would you say you are concentrating better?"
B Nortriptyline is a secondary amine with a good side effect profile. It is somewhat sedating, which is helpful to patients with insomnia. The other options are not considered outcomes for this medication.
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 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 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.
A patient diagnosed with depression has taken a selective serotonin reuptake inhibitor (SSRI) for 1 month. The nurse should use direct questions to evaluate which potential side effect? a. Aggressive impulses b. Sexual dysfunction c. Paranoid delusions d. Weight gain
B SSRIs often produce sexual dysfunction, such as decreased libido. Patients readily tell nurses about anticholinergic, gastrointestinal, and other side effects, but are not as forthcoming in reporting sexual problems. The nurse might need to ask directly to elicit this information. Patients are more willing to discuss the other options.
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.
A pregnant patient took selective serotonin reuptake inhibitors (SSRIs) during the third trimester of pregnancy. The newborn will be carefully assessed for which neonatal complication? a. Temperature dysregulation b. Serotonin syndrome c. Seizure disorder d. Diabetes
B The neonate whose mother has received SSRIs might experience respiratory depression, hypoglycemia, tremor, and low birth weight as part of neonatal serotonin syndrome. The disorder normally is resolved within 2 weeks of birth. The other options are not usually seen as a result of in utero exposure to SSRIs.
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.
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.
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 diagnosed with depression is prescribed the tricyclic antidepressant (TCA) bupropion. What is the benefit of this medication for nonhospitalized patients? a. It has antianxiety properties as well as antidepressant effects. b. It lowers the seizure threshold to a lesser extent than TCAs. c. There is reduced potential for lethal overdose. d. It stimulates appetite and weight gain.
C Bupropion has no lethal-overdose potential, making it well suited for use in outpatient treatment of depression. Bupropion has a narrow therapeutic index but is far less lethal than TCAs or monoamine oxidase inhibitors (MAOIs). However, it might cause agitation, anxiety, seizures, anorexia, and weight loss.
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.
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.
A patient tells the nurse, "I've stopped taking sertraline because the drug made me impotent. Which statement by the nurse will provide the best patient support? a. "Your doctor still wants you to continue taking your medication." b. "Have you talked with your therapist regarding your feelings about sex?" c. "Let's talk with your doctor. Changing your medication might be a possibility." d. "Our priority is to treat your depression. Impotence can be addressed in a few weeks."
C Selective serotonin reuptake inhibitor (SSRI) commonly causes sexual dysfunction. Changing to another type of antidepressant or adding bupropion in small doses can be helpful. The other options are not compassionate or therapeutic.
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.
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.
A patient prescribed phenelzine reports a sudden headache and palpitations. What is the nurse's initial intervention when observing the patient demonstrating dilated pupils and diaphoresis? a. Assess for cogwheel rigidity. b. Notify the health care provider. c. Assess the patient's blood pressure. d. Withhold the morning dose of phenelzine.
C The patient's symptoms are suggestive of hypertensive crisis. It is vital to know whether or not the blood pressure is elevated, so obtaining the blood pressure is the necessary first action. The most probable reason for the reaction would be drug-food interaction. The nurse may notify the health care provider and withhold the morning dose as subsequent actions. Cogwheel rigidity is associated with antipsychotic medications.
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.
A nurse teaches a patient taking a monoamine oxidase inhibitor (MAOI) about important dietary guidelines. Which nutritional choices by the patient indicate that the teaching was effective? (Select all that apply.) a. Sausage b. Avocados c. Pork chops d. Strawberries e. Chocolate chip cookies
C, D The patient must avoid foods high in tyramine so as to prevent a hypertensive crisis. Sausage, avocados, and chocolate contain significant amounts of tyramine.
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.
A patient prescribed fluoxetine is being changed to tranylcypromine. The nurse provides education on this change that will include a time lapse between the last dose of fluoxetine and the first dose of tranylcypromine of at least how long? a. 7 days. b. 14 days. c. 3 weeks. d. 6 weeks.
D Drugs that have a high probability for serious interactions (e.g., monoamine oxidase inhibitors {MAOIs} like fluoxetine) will need to be withheld for up to 6 weeks or more as fluoxetine is washing out of the system. The remaining options are too short an interval.
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.
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.
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.
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.
A secondary amine tricyclic antidepressant is prescribed for a patient. The medication will significantly increase the availability of which neurotransmitter? a. GABA b. Glutamate c. Serotonin d. Norepinephrine
D Secondary amines increase the availability and enhance the action of norepinephrine. They do have a similar effect on any of the other options.
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.
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.
What are the priority history assessments for a patient beginning amitriptyline therapy? (Select all that apply.) a. Agranulocytosis b. Seizures c. Sexual dysfunction d. Orthostatic hypotension e. Blurred vision
D, E Tricyclic antidepressants (TCAs) like amitriptyline produce anticholinergic (blurred vision) and antiadrenergic (orthostatic hypotension leading to falls and arrhythmias) side effects. Gastrointestinal symptoms, sexual dysfunction, and weight variations are related to selective serotonin reuptake inhibitor (SSRI) therapy. Seizures are seen with bupropion therapy. Agranulocytosis is not considered a major problem with any of the groups of antidepressants.
A patient tells the nurse, "I want to have sex with you." Which nursing responses are appropriate? Select all that apply. a. "I will forget you said that." b. "Your suggestion frightens me." c. "You must keep your distance." d. "Sex is not part of our relationship." e. "We are here to work on your problems."
D,E
Delusions
False belief not held by others in the same culture that can be nonbizarre and potentially possible, such as some jealous or persecutory false beliefs, or bizarre and not reality based, such as thought broadcasting or thought insertion. They may be paranoid, grandiose, somatic, erotic, nihilistic, guilty, bizarre, or referential in nature.
Hallucinations
False sensory perceptions in the absence of an external stimulus. They may be auditory, visual, tactile, olfactory, or gustatory in nature.
Hypnagogic and hypnopompic hallucinations, derealization, and depersonalization are considered A. signs of serious organic brain damage B. within the normal range of experience C. expressive of the potential for acting on violent thoughts D. sensations experienced by the client that have real external stimuli
Hypnagogic and hypnopompic hallucinations, derealization, and depersonalization are considered B. within the normal range of experience
Collateral history
Information about a client obtained from the client's family, friends, colleagues, or mental health professionals.
Coping skills
Mechanisms people use to manage internal and external stressors; may be adaptive or maladaptive.
Research findings show a high level of co-morbidity between mental illness and A. substance abuse B. socioeconomic status C. aging D. work history
Research findings show a high level of co-morbidity between mental illness and A. substance abuse
The visible expression of a client's mood is referred to as A. mannerism B. affect C. insight D. dysarthria
The visible expression of a client's mood is referred to as B. affect
The nurse will probably spend more time on the orientation phase of the nurse-patient relations with which patient? a. The highly distrustful teenager who ran away from an abusive home situation b. The young mother who wants to return home to her young children c. The older adult who is admitted for 3 days for adjustments to his medication regime d. The middle-aged adult who voluntarily admitted himself for drug detox treatment
a. rationale: The nurse concentrates on nursing approaches in a particular phase, depending on the status and needs of individual patients. For example, approaches used in the orientation phase have priority when the patient is highly suspicious, because a need exists to develop trust with the patient. The distrustful patient will require additional interventions associated with the orientation phase. For the patient with good insight and motivation such as the young mother and the middle-aged adult, approaches in the working phase are most important because they concentrate on problem solving and change. If the patient is to be admitted for only 3 days, then approaches used in the termination phase are critical because of the need for formalizing plans for follow-up care and referrals to other services along the continuum of care.
The nurse believes that a patient is having emotional pain. Which remark is most therapeutic? a. "I hear how painful this is for you. I would like to help you deal with it." b. "I'm so sorry this has happened to you. You don't deserve it." c. "What would you like me to do to help you through this?" d. "I don't think this is as serious as you believe it is."
a. "I hear how painful this is for you. I would like to help you deal with it."
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.
A patient shouts at a nurse who just entered the room, "You're an incompetent fool. Leave me alone." The nurse's response should be based on which rationale? a. The anger was created by a situation or significant person, not the nurse. b. The reaction probably results from transference and countertransference. c. The patient is probably reacting to fear of loss of emotional control. d. The patient has a right to openly express negative feelings.
a. The anger was created by a situation or significant person, not the nurse.
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.
A patient hospitalized for 6 days has made little progress toward outcomes written at the time of admission. The nurse decides that the lack of progress toward goals indicates that: a. needs for reassessment exist. b. discharge should be delayed. c. nursing diagnoses were incorrect. d. nursing interventions were inadequate.
a. needs for reassessment exist.
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 nurse caring for a hyperactive patient should be particularly concerned about assessing: a. physical safety. b. emotional trauma. c. manipulative behaviors. d. feelings about the relationship.
a. physical 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.
A patient has identified the need for better anger management and tells the nurse, "I'm afraid that someday I might explode." The best strategy for reducing this patient's fear of losing control is to: a. talk about these feelings openly and directly. b. discuss feelings in general without reference to the patient. c. avoid talking about the feelings until the patient feels comfortable. d. reassure the patient that expressing feelings is the first step to resolving them.
a. talk about these feelings openly and directly.
Objective data obtained in an initial assessment of a patient are of particular value when: a. the patient is too ill to participate. b. the patient's admission is involuntary. c. family members have admitted the patient. d. the patient has been transferred from a subacute setting.
a. the patient is too ill to participate.
Following the admission interview, a spouse of a patient asks the nurse, "Why did you ask my partner all those questions? Some of them had nothing to do with current problems." The nurse's best response is, "Those questions help us understand: a. the patient's current status." b. the complete family history." c. the patient's past experiences." d. what the patient's prognosis will be."
a. the patient's current status."
An adult with paranoid schizophrenia is hospitalized. This patient has frequent auditory hallucinations and walks about the unit, muttering. To use psychotherapeutic management effectively, it is most important for the nurse to: a. understand the disease process of schizophrenia. b. minimize contact between this patient and other patients. c. administer PRN medication before interacting with the patient. d. use behavior modification to decrease the frequency of hallucinations.
a. understand the disease process of schizophrenia. An understanding of psychopathology is the foundation on which the three components of psychotherapeutic management rest; it facilitates therapeutic communication and provides a basis for understanding psychopharmacology and milieu management. Minimizing contact between the patient and others and administering PRN medication indiscriminately are nontherapeutic interventions. Using behavior modification to decrease the frequency of hallucinations would need to be incorporated into the plan of care.
Which statement made by the nurse best demonstrates the technique of self-disclosure when discussing a depressed patient? a. "Depression runs in my family. Does any family member of yours have depression too?" b. "Feeling lonely can make me depressed. What kinds of things make you feel depressed?" c. "Medication helped me when I was depressed. Have you ever been prescribed an antidepressant medication?" d. "I was so depressed once, I actually thought about suicide. Have you ever thought about hurting yourself?"
b. rationale: A self-disclosure should be planned, patient-centered, and goal-directed. The disclosure guides the conversation toward the exploration of patient problems, issues, and needs. Such disclosures help the patient clarify issues and feel less vulnerable and more normal. Therapeutic self-disclosure facilitates comfort, honesty, openness, and risk taking but never burdens patients with the nurse's problems. Directing the conversation to possible triggers is the best example of self-disclosure, since it opens the topic and divulges very general personal information. Sharing a family history of depression, the fact that the nurse was once prescribed antidepressant medication, and that suicide was once considered constitute personal information that is inappropriate to share and burdensome to the patient.
The nurse performing a mental status examination wants to assess for hallucinations. The nurse should ask: a. "Can you tell me where you are now?" b. "Do you hear or see things when others don't?" c. "Do your moods shift more than those of other people?" d. "What would you do if you found a stamped, addressed letter on the floor?"
b. "Do you hear or see things when others don't?"
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.
Which nursing intervention will initially be most helpful for trust building with a suspicious patient? a. Enforcing rules b. Keeping appointments and promises c. Agreeing not to document the patient's disclosures d. Openly challenging unclear statements by the patient
b. Keeping appointments and promises
Which guideline should a nurse use when applying the components of psychotherapeutic management to the care of a patient with mental illness? a. The nurse's role in milieu management is secondary to that of social work. b. Omitting any one component usually will result in less effective treatment. c. The most important element of psychotherapeutic management is drug therapy. d. A therapeutic nurse-patient relationship is the most important aspect of treatment.
b. Omitting any one component usually will result in less effective treatment. The three components listed as choices a, c, and d above work together to provide the best treatment outcomes. When one element is missing, treatment is usually compromised. No single element is more important than the others; however, patients' needs govern the application of the components and permit judicious use.
A nurse considers interventions for a diabetic patient who needs to change eating habits and lose weight. The nurse will base strategies on which principle? a. The nurse's primary responsibility is to encourage the change. b. Patient-initiated change is more successful than imposed change. c. For successful change, both the benefit and the risk to the patient must be high. d. Patients value advice from nurses because of the trusting dimensions of the relationship.
b. Patient-initiated change is more successful than imposed change
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.
During an MSE a patient says, "I am a special messenger sent to provide the world a cure for cancer." The patient's statement indicates the presence of: a. a phobia. b. a delusion. c. hypervigilance. d. loose associations.
b. a delusion.
Assessment findings by the multidisciplinary team after a patient-intake interview are used primarily to: a. confirm ongoing discharge planning. b. expand and confirm the initial assessment. c. verify the appropriateness of nursing diagnoses. d. analyze the patient's feelings about hospitalization.
b. expand and confirm the initial assessment.
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.
A patient says, "I went out drinking only one time last week. At least I'm trying to change." The nurse responds, "I appreciate your effort, but you agreed to abstain from alcohol completely." The nurse is: a. using cognitive restructuring. b. preventing manipulation. c. showing empathy. d. using flooding.
b. preventing manipulation.
A patient attends outpatient programs at a community mental health center and meets with the primary nurse regularly. Last week, the patient's haloperidol (Haldol) dose was reduced from 5 mg to 2 mg daily to decrease side effects. The nurse will need to monitor changes in: a. the activity schedule at the center. b. the nature of the patient's symptoms. c. attention given to the patient by other staff. d. balance among psychotherapeutic management elements.
b. the nature of the patient's symptoms. It will be necessary for the nurse to assess for exacerbation of the patient's symptoms of psychosis as well as for an amelioration of side effects. Dosage decrease might lead to the return or worsening of positive symptoms such as hallucinations and delusions, and negative symptoms such as blunted affect, social withdrawal, and poor grooming.
in order to be successful in the long run, patients need to
be able to establish healthy, supportive relationships with others in community
A patient experiencing a loss of reality believes in the angry voices in her head. The nurse will respond to a newly admited patient who is experiencing auditory hallucinations. The nurse initially makes which response? a. "There are no voices in your head." b. "Try to ignore them by listening to your favorite music ." c."I am not hearing those voices, but I understand that you do." d. "Just listen to my voice to distract yourself."
c rationale: Initially the nurse acknowledges and respects the patient's experience while presenting reality and avoiding reinforcement of the hallucinations. Stating that there are no voices discounts and minimizes the patient's experience. It is nontherapeutic and may be argumentative. More teaching and support of the patient will be required before distraction can be implemented, and even then it may not be possible or realistic for the patient.
A newly admitted patient is depressed and fears her husband will ask for a divorce. She begins to cry during the initial assessment interview. An effective nursing strategy would be to: a. postpone the assessment for later. b. avoid comment on her tears, and continue the assessment. c. stop and offer her a tissue. d. ask her why her husband wants to divorce her.
c. rationale: Stopping to offer the patient a tissue allows the patient (and the nurse) to pause, think, and collect herself. Assessment initially may not be postponed; data forms the basis for the plan of care, and the nurse-patient interaction initiates or establishes the therapeutic relationship. Making the observation is therapeutic and validates support of the patient. "Why" questions are considered nontherapeutic and could engender anger and/or defensiveness.
Which statement made by the nurse indicates a need for additional instructions concerning the nursing role in promoting a change in a patient's behavior? a. "How long do you think it will take for you to stop smoking?" b. "You should be very proud of the way you handled your anger today." c. "I think you will be much happier when you leave your abusive partner." d. "What do you think you can do to avoid the triggers that cause you to abuse alcohol?"
c. rationale: he nurse should not give the patient advice to leave but rather help the patient solve her own problems. The nurse encourages short-term, realistic, and achievable goals that have been made by the patient. Asking the patient to consider timelines, praising the patient for positive changes, and helping with the identification of triggers are all appropriate nursing interventions that focus on the promoting of change. *telling her to do something instead of giving therapy
What is the initial intervention when a patient acknowledges to the nurse that he is hearing voices? a. Minimizing stimulation by moving the patient to an area that is quiet and dimly lighted b. Seating the patient in front of the television so the program can serve as a distraction from the voices c. sking the patient to describe what the voices are saying d. Reassuring the patient that the staff will keep him safe
c. rationale: If the patient acknowledges hearing something that the nurse cannot hear, the nurse can then ask, "Tell me what you hear." Moving the patient to a low-stimuli area will not serve to help control the voices. The voices from the television are not likely to serve as a distraction. Reassuring the patient that staff will keep him safe is not necessarily inappropriate, but the need for safety cannot be determined until it is known what the patient is hearing. *need to ask about voices in case they try to harm themselves you can take control
The new RN is experiencing difficulty knowing how to terminate a relationship with a patient. The preceptor states: a. "If the relationship has been short, termination may not be necessary." b. "Just say good-bye and good luck." c. "Thank the patient for working with you, and say how you valued the experience." d. "Try to move through the termination phase as quickly as possible."
c. rationale: Thanking the patient and acknowledging the value of the experience offers respect and support to the patient while validating the importance of the relational opportunity for the nurse. Termination is always appropriate and necessary therapeutically. Wishing the patient "good luck" is not therapeutic but instead is casual and informal. Termination should not be rushed, and—depending upon the length of time in the relationship—planning and discussion of termination for the patient and nurse are important.
Which statement by a patient would the nurse interpret as willingness to collaborate in the nurse-patient relationship? a. "I know you are here to help me, and will do whatever you tell me to do." b. "I didn't want to deal with this at first, but I'm glad you made me face it." c. "I realize that I have some issues that I need help resolving." d. "I will do anything to get out of this hospital."
c. "I realize that I have some issues that I need help resolving."
A novice nurse says, "I have more important things to do than play games with patients. These activities are not a worthwhile use of my time." Select the nurse manager's best response. a. "Games are part of the therapeutic milieu." b. "Patients need a break from intensive individual therapy." c. "Informal activities help patients develop social skills and take risks." d. "Please review material on the psychotherapeutic management model."
c. "Informal activities help patients develop social skills and take risks."
As a patient and nurse move into the working stage of a therapeutic relationship, the nurse's most beneficial statement is: a. "I want to be helpful to you as we explore your problems and the way you express feelings." b. "A good long-term goal for someone your age would be to develop better job- related skills." c. "Of the problems we have discussed so far, which ones would you most like to work on at this time?" d. "When someone gives you a compliment, I notice that you become very quiet and appear uncomfortable."
c. "Of the problems we have discussed so far, which ones would you most like to work on at this time?"
An inpatient says, "Last time I was here, a primary nurse talked with me every day. This time, different nurses work with me. How can I make progress?" Select the nurse's best response. a."Your comments are interesting. With your permission I will share them with the treatment team." b. "We are using a new system because of managed-care requirements. We are hopeful it will be effective." c. "Shift reports, care plans, and progress notes help different nurses work with all patients toward their individual goals." d. "It sounds like you are feeling dissatisfied with your care. After you are discharged, you will receive a form to provide feedback."
c. "Shift reports, care plans, and progress notes help different nurses work with all
Which patient behavior would require the most immediate limit-setting? a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. A patient shouts at a roommate, "You are perverted! You watched me undress." d. During dinner, a patient manipulates an older adult patient to obtain a second dessert.
c. A patient shouts at a roommate, "You are perverted! You watched me undress."
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 patient is hospitalized for severe depression. Knowing that the patient will be discharged after a short stay, what is the nurse's first priority? a. Maximize the benefits of milieu management. b. Immediately begin to explore acute patient issues. c. Develop a goal-directed, problem-centered relationship. d. Choose a specific theoretical model as the basis for care.
c. Develop a goal-directed, problem-centered relationship.
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.
A nurse says, "What step would you like to take next to resolve this issue?" The patient stands up and shouts, "You are so controlling! You want me to do everything your way." What is the likely basis of the patient's behavior? a. Projection b. Dissociation c. Transference d. Emotional catharsis
c. Transference
The primary element required to match individual patient needs with appropriate services is proper: a. planning. b. evaluation. c. assessment. d. implementation.
c. assessment Proper assessment is critical for being able to determine the appropriate level of services that will provide the patient with optimal care at the lowest cost. The decision tree for the continuum of care establishes this fact.
A patient playing pool with another patient throws down the pool cue and begins swearing. The nurse should initially intervene by: a. asking other patients to leave the room. b. calling for assistance to restrain the patient. c. suggesting a time-out in the patient's room. d. restating rules of the milieu related to swearing.
c. suggesting a time-out in the patient's room
Complete this goal statement for a newly admitted patient in the orientation stage. "By the end of the orientation stage of the therapeutic relationship, the patient will demonstrate: a. greater independence." b. increased self-responsibility." c. trust and rapport with two staff members." d. ability to problem-solve one issue."
c. trust and rapport with two staff members."
Select the best description of nursing practice in the psychiatric setting. a. The nurse primarily serves in a supportive role to other members of the team. b. The multidisciplinary approach eliminates the need to clearly define the responsibility of nursing. c. Clearly differentiated nursing actions have been identified that distinguish nursing from other professions. d. Although professional role overlap exists, nursing offers unique contributions to psycho-therapeutic management.
d. Although professional role overlap exists, nursing offers unique contributions to psychotherapeutic managemnet. Professional role overlap cannot be denied; however, nursing is unique in its focus on and application of psychotherapeutic management. Psychiatric social workers do not have expertise in physical care. Ideally, all team members support each other.
A patient with a history of self-mutilation says to the nurse, "I want to stop hurting myself." What is the initial step of the problem-solving process to be taken toward resolution of a patient's identified problem? a. Deciding on a plan of action b. Determining necessary changes c. Considering alternative behaviors d. Describing the problem or situation
d. Describing the problem or situation
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.
A nurse and patient who developed a therapeutic relationship enter into the final phase of their relationship as the patient prepares for discharge. An important nursing intervention for this stage is for the nurse to: a. provide structure and intensive support. b. inform the patient of the progress made. c. encourage the patient to describe goals for change. d. discuss feelings about termination with the patient.
d. discuss feelings about termination with the patient.
A depressed adult is hospitalized after a suicide attempt. The patient receives an antidepressant medication, is closely supervised, attends a variety of group therapies and activities, watches television during free time, and talks to visitors in the evening. Which additional intervention is needed in the patient's care? a. Milieu therapy b. Adequate drug therapy c. Increased contact with significant others d. Meaningful communication with nursing staff
d. meaningful communication with the nursing staff. Two of the three elements of psychotherapeutic management are present: psychopharmacology and milieu management. There is no evidence that the psychotherapeutic nurse-patient relationship exists. Maintaining contact with significant others is not considered an element of the psychotherapeutic management model.
The nurse writing a discharge summary for a patient should include achievements as well as: a. care plan updates. b. a list of patient strengths. c. effective nursing interventions. d. outcomes that still need to be addressed.
d. outcomes that still need to be addressed.
A newly admitted patient continually touches the nursing staff members and makes sexual innuendoes when interactions are attempted. The initial therapeutic manner of managing such behavior is to: a. avoid the patient until the behaviors cease. b. demand firmly that the patient cease all inappropriate touching. c. ask the patient to explain why the sexual innuendoes occur. d. explain that the behavior is inappropriate and must stop
d: rationale: Patients generally stop these behaviors when asked and should be reminded that these actions are inappropriate. The nurse then discusses the underlying need. If the behaviors continue, then setting limits can be stronger. Avoiding the patient without an explanation is incongruent with professionalism. Demands are ineffective and disrespectful. While a discussion concerning the behavior is appropriate, it is not the initial response.
psychoanalytic model
unconscious processes basic for motivation and behavior ex: disruption in early parent child relationships lead to future relationship problems for children
