Psych T1

Your client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which adverse reaction? A. Extrapyramidal reaction B. Tardive dyskinesia C. Reye's syndrome D. Agranulocytosis

D. Agranulocytosis

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction? A. Dystonia B. Akinesia C. Akathisia D. Tardive dyskinesia

A. Dystonia

The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: A. Delusions. B. Hallucinations. C. Loose associations. D. Neologisms.

B. Hallucinations.

The nurse is aware that antipsychotic medications may cause which of the following adverse effects? A. Increased production of insulin B. Lower seizure threshold C. Increased coagulation time D. Increased risk of heart failure

B. Lower seizure threshold

The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? A. Planning short-term goals B. Making appropriate referrals C. Developing realistic solutions D. Identifying expected outcomes

B. Making appropriate referrals

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet.

D. The client is monitored by an ankle bracelet.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? a. Abnormally high blood flow to the frontal lobes b. Atrophy of both the limbic structures and cerebellum c. Abnormally small fissures on the surface of the brain d. Atrophy of the lateral and/or third ventricles of the brain

d. Atrophy of the lateral and/or third ventricles of the brain

A client who has taken an antipsychotic for years develops involuntary, repeated movements of the muscles of the face, trunk, arms, and legs. The client has which of the following? 1.Neuroleptic malignant syndrome (NMS) 2.Akinesia 3.Tardive dyskinesia 4.Drug-induced parkinsonism

3.Tardive dyskinesia

Which of the following characteristics of schizophrenia is a negative symptom? 1.Withdrawal 2.Bizarre behavior 3.Hallucinations 4.Speech problems

1.Withdrawal

Psychotropic medications that block the acetylcholine receptor may result in which of the following side effects? a. dry mouth b. sexual dysfunction c. nausea d. priapism

a. dry mouth

Which of the following are characterisitcs of a holistic approach to psychiatric-mental health nursing care? (Select all that apply) 1. The biological aspect of illness is considred 2. Physical symptoms are interrelated with mental factors 3. Mental illness does not impact physiologi homeostasis 4. The client's socioeconomic status is considered in planning care 5. The client's spiritual needs are not considered when planning nursing care

1. Rationale: A holistic approach to psychiatric-mental health nursing care examines how physiologic changes that occur with an illness affect emotional well-being. 2. Rationale: Physical symptoms can directly impact a client's emotional well-being and mental health. 4. Rationale: A client's socioeconomic status can directly affect a client's ability to access health care.

Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 1. Monthly blood tests will be necessary. 2. Report a sore throat or fever to the physician immediately. 3. Blood pressure must be monitored for hypertension. 4. Stop the medication when symptoms subside.

2. Report a sore throat or fever to the physician immediately.

The nurse is preparing a care plan for a client exhibiting negative symptoms of schizophrenia. Which are indicative of negative symptoms? Select all that apply. a. Short attention span b. Delusional thoughts c. Inappropriate body movements d. Loose associations of thought e. Limited ability to communicate verbally

a. Short attention span e. Limited ability to communicate verbally

The nurse is teaching the patient about the side effects of Clozaril. Which of the following potentially fatal side effects will the nurse warn the patient should be brought to the attention of his physician? a. agranulocytosis b. tardive dyskinesia c. neuroleptic malignant syndrome d. dystonia

a. agranulocytosis

Julie, a 49-year-old patient diagnosed with schizophrenia at 22 years old, is taking risperidone (Risperdal). Which of the following nursing assessments is the priority assessment with Julie? a. Monitoring blood levels to avoid toxicity b. Monitoring for abnormal involuntary movements c. Observing for secondary mania d. Observing for memory changes

b. Monitoring for abnormal involuntary movements Risperidone has the highest rate of extrapyramidal side effects (EPSs) of the second-generation antipsychotic medications, thus making it imperative to monitor for EPSs. Risperidone is not monitored with blood levels and does not cause mania or memory changes.

A client is receiving fluphenazine (Prolixin) daily. The nurse should teach the client to take which measure to minimize common side effects of this medication? a. Monitor the temperature daily. b. Use hard sour candy or sugarless gum. c. Eat snacks at midmorning and at bedtime. d. Have the blood pressure checked once a week.

b. Use hard sour candy or sugarless gum.

The experienced psychiatric nurse shares with the novice nurse that effective nursing care for the delusional client depends on (Select all that apply.) a) Providing the client with logical proof that the delusion is neither real nor valid b) Supporting the delusion only when the client is extremely agitated c) Expecting the client to adhere to all unit rules d) Managing the milieu so as to minimize situations that will frustrate or anger the client e) Being relaxed during frequent nurse-client interactions

c) Expecting the client to adhere to all unit rules d) Managing the milieu so as to minimize situations that will frustrate or anger the client e) Being relaxed during frequent nurse-client interactions

A client who has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature of 103F, and trouble breathing on day 3. The nurse interprets these findings as indicating which of the following? a. Drug induced parkinsonism b. Tardive Dyskinesia c. Neuroleptic malignant syndrome d. Extrapyramidal adverse effects

c. Neuroleptic malignant syndrome

Serving as a substitute for another, such as a parent or sibling, is an example of which nursing role? a. teacher b. leader c. surrogate d. counselor

c. surrogate

The nurse is caring for a client who has been treated with long-term antipsychotic medication. During the assessment, the nurse checks the client for tardive dyskinesia. If tardive dyskinesia is present, what would the most likely assessment findings be? a. Severe headache, flushing, tremors, and ataxia b. Abnormal breathing through the nostrils, accompanied by a thrill c. Severe hypertension, migraine headache, and "marbles in the mouth" syndrome d. Abnormal movements and involuntary movements of the mouth, tongue, and face

d. Abnormal movements and involuntary movements of the mouth, tongue, and face

When preparing the teaching plan for a client who is to start clozapine (Clozaril), which of the following is crucial to include? a. Description of akathisia and drug induced parkinsonism b. Measures to relieve diarrhea c. The importance of reporting insomnia d. An emphasis on the need for weekly blood tests

d. An emphasis on the need for weekly blood tests due to the risk for agranulocytosis

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

d. Get up slowly when changing positions.

When conducting a mental status examination with a client who has a diagnosis of schizophrenia the client states "Im being followed, its not safe. They're monitoring my every move." In which of the following areas of the mental status examination should the nurse document this information. a. Insight b. Quality of speech c. Judgement d. Thought content

d. Thought content