Psyche Exam 3

A patient who became severely depressed after losing her job tells the nurse that she is not worth the time the nurse spends with her. The patient often mentions that she is "the worst person in the world." On the basis of this data, which nursing diagnosis is most appropriate? a. Powerlessness b. Defensive coping c. Low self-esteem d. Disturbed identity

chapter 13 original book

Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

D Nonverbal communication is usually considered more powerful than verbal communication. Downward-casted eyes suggest feelings of worthlessness or hopelessness.

A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.

A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision, safety, and recreational and social interaction during the day. Family cares for the patient during the evening and night. Which type of facility would meet this patient's needs? a. Adult day care program b. Skilled nursing facility c. Partial hospitalization d. Psychotherapy group

A A day care program provides recreation and social interaction. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services, usually on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A psychotherapy group is not appropriate and would not meet the patient's needs.

A patient asks, "What advantage does a durable power of attorney for health care have over a living will?" The nurse should reply, "A durable power of attorney for health care: a. gives your agent authority to make decisions during any illness if you are incapacitated." b. can be given only to a relative, usually the next of kin, who has your best interests at heart." c. can be used only if you have a terminal illness and become incapacitated." d. cannot be implemented until 30 days after the papers are signed."

A A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individual's agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individual's behalf.

A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response? a. "It is a self-help group with the goal of sobriety." b. "It is a form of group therapy led by a psychiatrist." c. "It is a group that learns about drinking from a group leader." d. "It is a network that advocates strong punishment for drunk drivers."

A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

An elderly patient must be physically restrained. Who is responsible for the patient's safety? a. Nurse assigned to care for the patient b. Nursing assistant who applies the restraint c. Family member who agrees to application of the restraint d. Health care provider who prescribed application of restraint

A Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but they remain responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes.

Which statement provides the best rationale for monitoring the severely depressed patient closely as treatment proceeds? a. As depression lifts, physical energy and cognitive organization improve and enable the patient to carry out a plan for suicide. b. Effective therapy involves confronting the depressed patient about inadequacies that the patient has been unwilling to face. c. Severely depressed persons tend to conceal their feelings and true intentions related to suicide and should not be trusted. d. Severely depressed persons tend to be labile; their mood can change quickly in response to even the smallest stressors.

A Antidepressant medication and other treatment do improve the features of depression. As the depression lifts, the patient regains more physical energy and more organizational ability at a time when he or she may still have suicidal ideation. Treatment does not involve confronting the patient about inadequacies. Severely depressed patients may not always be candid and can experience variations in their mood, but these factors are not the major issues likely to temporarily increase the risk of suicide as the patient begins to get better.

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

A patient is comatose after ingesting six codeine tablets. The patient's friend says, "Often my friend drinks along with taking more of the drug than is prescribed." Use of alcohol with this drug: a. has a synergistic effect. b. diminishes the drug's effect. c. causes no effect. d. stimulates metabolism of the drug.

A Both codeine and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

An older adult patient takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium b. dementia c. amnestic syndrome d. Alzheimer's disease

A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"

B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority.

A patient with depression is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should: a. explain how to manage hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. update the patient's mental status examination.

A Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Updating a mental status examination is unnecessary.

A selective serotonin reuptake inhibitor is prescribed for an elderly patient with depression. Nursing assessment should include careful collection of information regarding: a. other prescribed medications and over-the-counter products used. b. evidence of pseudoparkinsonism or tardive dyskinesia. c. history of psoriasis and any other skin disorders. d. history of diarrhea and electrolyte imbalances.

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.

The treatment team plans care for a person diagnosed with paranoid schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each diagnosis primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the symptoms of schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

A Dual diagnoses clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Establishing random eye movement latency d. Assisting the patient to identify and test negative thoughts

A During the immediate posttreatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Establishing random eye movement latency is neither possible nor a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate posttreatment period because the patient may be confused.

A depressed patient who is scheduled to receive electroconvulsive therapy this morning asks the nurse, "How is this treatment supposed to help me?" The best reply would be: "Electroconvulsive therapy seems to ____________." a. increase the activity of brain chemicals involved in mood b. interfere with one's memory of why he's feeling depressed c. serve as a punishment so you can stop punishing yourself d. open your mind to learning and trying new ways of coping

A ECT seems to alter neurotransmitter activity, consistent with the biochemical theory of the cause of depression. The other options distort information from other etiological theories and are not supported by research on the mechanism of action of electroconvulsive therapy.

A nurse with a history of narcotic dependence is found unconscious in the hospital locker room after overdosing. The nurse is transferred to the inpatient chemical dependence unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance use. b. Pointing out that work problems are the result, but not the cause, of substance dependence. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

A Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

The nurse should complete the Geriatric Depression Scale as part of the assessment if an elderly patient answers which question affirmatively? a. "Would you say your mood is often low?" b. "Are you having any trouble with your memory?" c. "Have you noticed an increase in your alcohol use?" d. "Do you often experience moderate to severe pain?"

A Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood.

In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

A Hydromorphone (Dilaudid) is an opiate drug. The correct answer is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The distracters are desired outcomes later in the plan of care.

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you began feeling depressed."

A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.

The patient tells his primary nurse "I get into trouble because I have hair-trigger responses. I shoot from the hip. Lots of times that gets me into a mess." Which response would be most therapeutic? a. "Let's look at ways to help you slow it down and think before acting." b. "It might help to explore how you came to be that way-any ideas?" c. "I'll bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness and motivation to change."

A Interventions exist to slow reactivity to at least some forms of provocation for the patient. Educating the patient about these techniques provides other coping options when faced with those same provocations in the future. Although exploring factors that contributed to the patient's current behavioral patterns can be helpful, there are effective strategies the patient can use to change behavior that are not dependent on knowing the origins of the behavior (which many times are unknown to the patient). Asking the patient about stories serves no therapeutic purpose, and maladaptive behavior can be reinforced by showing interest in them. Insight is not necessarily indicative of readiness or motivation to change.

Which suicide plan is most lethal? a. Jumping from a high, deserted bridge late at night b. Overdosing on aspirin with codeine while home alone c. Turning on the oven and letting the gas work during the night d. Cutting one's wrists 15 to 20 minutes before the spouse returns home

A Jumping from a high, deserted bridge late at night is a highly lethal method with very little opportunity for rescue. Overdosing and gas from an oven are potentially lethal but work more slowly and provide significant time for potential rescue. Wrist cutting, depending on the rate of blood loss, can be lethal but usually requires time to reach a dangerous degree of exsanguination, providing an opportunity for rescue.

A patient in an alcohol rehabilitation program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance

A Low self-esteem is present when a patient sees him- or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome for the nursing diagnosis Situational low self-esteem, related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date) . b. consent to take antidepressant medication regularly by (date) . c. initiate social interaction with another person daily by (date) . d. identify two personal behaviors that alienate others by (date) .

A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

A patient with depression does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective action. a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require "yes" or "no" answers. d. Frequently reassure the patient to reduce guilt feelings.

A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness.

Which intervention is appropriate for a patient with an antisocial personality disorder who frequently manipulates others? a. Refer the patient's requests and questions related to care to the case manager. b. Encourage the patient to discuss his or her feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

A Manipulative patients frequently make requests of many different staff members, hoping someone will give in. Having only one decision-maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

Which intervention would be appropriate for a patient with a nursing diagnosis of Ineffective coping as evidenced by manipulation of others? a. Refer patient requests and questions about care to the primary nurse. b. Provide negative reinforcement for any acting-out behavior. c. Ignore rather than confront inappropriate interpersonal behavior. d. Encourage the patient to discuss feelings of fear and inferiority.

A Manipulative patients frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and prevents playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. Ignoring behavior can in some cases help extinguish the behavior, but more typically, manipulative behavior responds better to judicious use of confrontation. Antisocial patients suppress or conceal such feelings if present and would be very unlikely to admit to them, let alone discuss them.

A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually a social drinker. I usually have one drink at lunch, two cocktails in the afternoon, wine with dinner, and a few drinks during the evening." Which defense mechanism is evident? a. Denial b. Projection c. Introjection d. Rationalization

A Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one's own personality.

A patient who has attempted suicide by taking a handful of ibuprofen (Motrin) is admitted to the mental health unit. She had attempted suicide three times previously, each by overdose on over-the-counter medications, and in each case was found by family or peers in time to prevent her death, eventually being admitted to this mental health unit each time. Which of the following nursing responses would be most appropriate? a. Search her and her belongings for pills and other dangerous objects, then minimize the attention given to her by staff in order to reduce secondary gains. b. When medically stable, confront her with her pattern of maladaptive coping, noting that the low lethality of her attempts suggests she is seeking attention. c. Discuss with her family ways that they can reduce her attention-seeking suicide gestures by keeping all medications locked and not responding to histrionic behavior. d. Place her on one-to-one observation because her history of previous attempts suggests she is at high risk of suicide; once medically stable, begin intensive psychiatric treatment.

A Most people who complete suicide have made at least one previous attempt, and a history of prior attempts is one of the strongest predictors of future risk. Some attempts may appear unlikely to have succeeded from the outset if the means was of low lethality (e.g., choking oneself with socks wrapped around the neck) or because circumstances would have led to them being rescued before harm results (e.g., an attempt initiated in front of witnesses). Many lay people and some staff tend to interpret such unlikely-to-succeed attempts as meaning that the person "wasn't really serious about suicide", that it was a (so-called) suicide gesture. In fact, often a depressed or psychotic person simply is too cognitively impaired to plan well to succeed at suicide. Assuming that overdosage on over-the-counter (OTC) medications is a low-lethality means is contradicted by the fact that many OTC meds are quite lethal, including common ones such as aspirin and acetaminophen. Further, identifying a serious attempt as "a gesture" (not serious) can increase the risk of suicide if it is perceived as a challenge or if the person feels they or their attempt are being ridiculed or not taken seriously. The person may respond by intensifying efforts and may succeed in a subsequent attempt. Confronting her with claims that she is attention-seeking suggests a lack of understanding of suicidality, pharmacology, and risk assessment. Speaking with her family as noted indicates that staff do not understand suicidality and do not appreciate the actual degree of risk represented. Although restricting access to means is desirable, OTC meds are readily available in the world, so it is important to understand that locking those meds already in the house does not necessarily mean the patient will be safe.

Which of these statements about suicide is accurate? a. The majority of persons who attempt suicide have given overt or covert indications of their intentions to others. b. A background in health care has a protective effect, leading to a lower rate of suicide among physicians and nurses than in the general public. c. Most persons with previous suicide attempts survived because they did not truly intend to die; they are at lower risk than those making their first attempt. d. Use of a low-lethality means or likelihood of being discovered in time to prevent death are merely suicide gestures, not genuine attempts.

A Most persons who later attempt suicide have given some indication of being at risk, of having ideation or intent related to suicide. The suicide rate among physicians and nurses is higher than in the general population; their special knowledge of pharmacology and physiology can make attempts more likely to be lethal. Most people who complete suicide have made at least one previous attempt, and a history of prior attempts is one of the strongest predictors of future risk. Some attempts may appear unlikely to have succeeded from the outset, because the means was one of low lethality (e.g., choking oneself with socks wrapped around the neck) or because circumstances would have led to their being rescued before harm resulted (e.g., an attempt initiated in front of witnesses). Many tend to interpret such unlikely-to-succeed attempts as meaning that the person "wasn't really serious about suicide," that it was a (so-called) suicide gesture. In fact, often a depressed or psychotic person simply is too cognitively impaired to plan well to succeed at suicide. Further, identifying a serious attempt as "a gesture" (not serious) can increase the risk of suicide if it is perceived as a challenge or if the person feels they or their attempt are being ridiculed or not taken seriously. The person may respond by intensifying efforts and may succeed in a subsequent attempt.

Select the nursing intervention necessary after administering naloxone (Narcan) to a patient with an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer span of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.

A 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.

Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Use warmers to maintain body temperature. d. Offer intellectual activities to stimulate concentration.

A Overdose of amphetamines can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. The patient is likely to have hyperthermia.

In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

A Patients who have ingested LSD respond well to being "talked down" by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, and never comes out for breaks or lunch. Which term best describes this behavior? a. Avoidant b. Dependent c. Histrionic d. Paranoid

A Patients with avoidant personality disorder are timid, socially uncomfortable, and withdrawn and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious and hostile and project blame.

A worker is characterized by her co-workers as "painfully shy" and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse's office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. With which diagnosis is this presentation most consistent? a. Avoidant b. Dependent c. Histrionic d. Paranoid

A Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing and expect and fear criticism. Individuals with dependent personality disorder are clinging, needy, and submissive. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention seeking. Individuals with paranoid personality disorder are suspicious, hostile, and project blame.

A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patient's sense of humor by telling jokes or riddles.

A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes and riddles meaningless.

What is the priority intervention for a nurse beginning to work with a patient with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Engage the patient in many community activities. d. Teach the patient how to match clothing.

A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

Which statement most accurately describes substance dependence? a. It is a lack of control over use. Tolerance and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the work of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves taking a combination of substances to weaken or inhibit the effect of another drug.

A Psychoactive substance dependence involves a lack of control over use, as well as tolerance and withdrawal symptoms when intake is reduced or stopped.

A patient with major depression was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion are associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient him- or herself to a pressured work schedule.

A Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient him- or herself to a pressured work schedule is less relevant than the correct rationale.

A college student who attempted suicide by overdose was treated in the emergency department. Because she had no available social supports, she was hospitalized. An outcome related to the nursing diagnosis Risk for self-directed violence is that the patient will: a. exercise self-control by refraining from attempting to harm herself. b. verbalize a desire and intent to live by the end of the second hospital day. c. demonstrate two new coping mechanisms by the fourth hospital day. d. discuss two personal strengths by the end of first week of hospitalization.

A Refraining from self-harm relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

A 76-year-old is regressed, indifferent, and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization? a. Remotivation b. Psychotherapy c. Reminiscence (life review) d. Group therapy would not be effective for this patient.

A Remotivation therapy is designed to resocialize regressed and apathetic patients by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work and hobbies related to the topic. Group leaders give members acceptance and appreciation.

A hospitalized patient with delirium misinterprets reality and a patient with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the present environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

A Risk for injury is the nurse's priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes are priorities and may not be realistic.

A patient with borderline personality disorder is hospitalized several times after self-mutilating episodes. The patient remains impulsive. Dialectical behavior therapy starts on an outpatient basis. Which nursing diagnosis is the focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore a high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority or related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.

A patient with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic

A SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

An alcohol-dependent patient admitted yesterday believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a: a. benzodiazepine, such as lorazepam (Ativan) or chlordiazepoxide (Librium). b. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). c. monoamine oxidase inhibitor, such as phenelzine (Nardil). d. narcotic analgesic, such as codeine.

A Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

Which documentation indicates the treatment plan of a patient with major depression was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

A Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding.

Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective? a. "Slept 6 hours straight, sang with activity group, eager to see grandchild." b. "Slept 8 hours, attended craft group, ate half of lunch, denies suicidal ideation." c. "Slept 10 hours, personal hygiene adequate with assistance, lost one pound." d. "Slept 7 hours on and off, reports "food has no taste", no self-harm noted."

A Sleeping 6 uninterrupted hours, actively participating in a group activity, and showing renewed interest in aspects of life previously important to the patient are indicators of progress. In the other choices, the patient attended activities but did not participate and maintained disinterest in food and/or impaired sleep. Patients may falsely deny suicide ideation, so self-reports are not fully reliable indicators, and "no self-harm noted", while desirable, also does not necessarily indicate that the desire to die has passed.

An adult with depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques

A Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patient's support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias.

The nurse has recently set limits for a patient with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're hateful." Which phenomenon is represented by this response? a. Splitting b. Denial c. Reaction formation d. Projection

A Splitting involves an inability to recognize that an individual can have both positive and negative qualities. Instead, when a person exhibits positive qualities, the patient idealizes that person, and when the person displeases the patient, the patient denigrates that same person. In this case, the patient is switching from idealization to denigration in response to a perceived negative aspect of the nurse. Denial is a defense mechanism wherein anxiety is reduced by blocking awareness or acceptance of whatever is causing the anxiety. Reaction formation involves unconsciously doing the opposite of an anxiety-provoking impulse. Projection is a defense mechanism wherein the person denies that the anxiety-provoking urge or thought exists and instead projects it onto others, so that the patient perceives others as having the thought or urge that is really their own (but unacceptable for them to face).

A patient with antisocial personality disorder tells Nurse A, "You're a much better nurse than Nurse B said you were." The patient tells Nurse B, "Nurse A's upset with you for some reason." To Nurse C the patient states, "You'd like to think you're perfect, but I've seen three of your mistakes this morning." Which nursing intervention would be most helpful for addressing this behavior? a. Hold a weekly staff meeting to discuss feelings and conflicts related to such behavior. b. Confront the patient and advise her that if she continues this, she will lose privileges. c. Get all staff to agree that any and all inappropriate behavior will simply be ignored. d. Evaluate the patient for a medication increase or transfer to a long-term facility.

A Staff splitting is occurring here, wherein the patient is setting up conflict among the staff to manipulate them into focusing on each other, thus taking the focus off the patient. It is important that staff help each other recognize this dynamic and develop a plan of response that all will use consistently. A weekly meeting to discuss the behavior is beneficial. Threatening the patient with loss of privileges implies that staff will punish or reject her if she is "bad," setting up a scenario perhaps similar to others wherein relationships have been conditional; this would increase abandonment fears and increase acting out behavior. Similarly, ignoring the patient each time her behavior is inappropriate is an excessive response that will heighten abandonment issues. Instead, staff should aim for a happy medium, wherein inappropriate behavior is labeled as such and addressed but not in a punitive or other manner that inadvertently reinforces it (e.g., negative attention can also be reinforcing). A medication increase or transfer would not help the patient behave more adaptively or appropriately. Staff supporting such measures are often experiencing countertransference and acting out their own negative feelings about the patient.

When working with a patient beginning treatment for alcohol dependence, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

Health care agencies receiving federal funds must provide patients written information about: a. advance health care directives. b. the financial status of the institution. c. how to sign out against medical advice. d. the institution's policy on resuscitation of individuals.

A The Patient Self-Determination Act of 1990 requires that patients receive clear information and have the opportunity to prepare advance directives.

Which documentation indicates that the treatment plan for a patient in an alcohol rehabilitation program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety 1 day at a time." Spoke with employer, who is willing to allow the patient to return to work in 3 weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and states, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."

A The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.

A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

A The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

Goals and outcomes for an older adult patient with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function b. identifying stressors negatively affecting self c. demonstrating motor responses to noxious stimuli d. exerting control over responses to perceptual distortions

A The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.

While the nurse at the personality disorders clinic is interviewing a patient, the patient constantly scans the environment and frequently interrupts to ask what the nurse means by certain words or phrases. The nurse notes that the patient is very sensitive to the nurse's nonverbal behavior. His responses are often argumentative, sarcastic, and hostile. He suggests that he is being hospitalized "so they can exploit me." The patient's behaviors are most consistent with the clinical picture of: a. paranoid personality disorder. b. histrionic personality disorder. c. avoidant personality disorder. d. narcissistic personality disorder.

A The diagnosis of paranoid personality disorder is defined by features such as pervasive mistrust of others; perceiving the motives of others as malevolent; believing that he is being exploited or victimized; perceiving inconsequential or neutral actions as containing slights, insults, or hidden threats; and an inability to trust even those closest to him. In that these patients perceive others as aligned against them, they tend to be defensive and accusative of others. The patient with histrionic personality disorder would be flamboyant and attention seeking. Persons with avoidant personality disorder would be excessively anxious and hypersensitive to criticism. The patient with narcissistic personality disorder would be grandiose, aloof, and disparaging of others.

A health care provider decides that an elderly patient's pain warrants use of a narcotic analgesic. Nursing staff must take action to reduce the risk of: a. falls. b. seizures. c. dehydration. d. incontinence.

A The incidence of falls increases when narcotic analgesics are used in the elderly. Safety is always a nurse's first priority. Medication does not place the patient at great risk for the distracters.

Select the priority outcome for a patient completing the fourth alcohol-detoxification program in 1 year. Prior to discharge, the patient will: a. state, "I know I need long-term treatment." b. use denial and rationalization in healthier ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

A The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, would not help the patient maintain sobriety.

A teacher comes to the mental health clinic saying a co-worker recently confronted her about behaviors that are annoying to other co-workers. She is now experiencing moderate to severe levels of anxiety. The co-worker told the patient that others find her very difficult because she is a perfectionist and micromanages the tasks of others on the teaching team, always demanding that things should be done according to her plans. The co-worker mentioned that the patient made everyone feel as though everything they tried was inadequate, and they feel frustrated and angry. The patient states she likes her co-workers and only wanted to help them be successful. The nurse realizes the patient's behaviors are most consistent with: a. obsessive-compulsive personality disorder. b. narcissistic personality disorder. c. histrionic personality disorder. d. schizoid personality disorder.

A The need to control at the expense of flexibility and openness, along with a preoccupation with orderliness and perfectionism, is consistent with obsessive-compulsive personality disorder. Narcissistic personality disorder involves grandiosity, the need for admiration, and lack of empathy. Histrionic personality disorder involves excessive emotionality and attention seeking. Schizoid personality disorder involves detachment from social relationships and a restricted range of expression in interpersonal settings.

An attractive nurse worked at a community hospital for several months, resigned, then took a position at another hospital. In the new position, the nurse volunteered to be the medication nurse. Several serious medication errors occurred in rapid succession. Investigation uncovered that the nurse was allowed to resign from the community hospital after diverting patient narcotics for own use. The nurse manager retrospectively identified which early indicator of the nurse's drug use? The nurse: a. sought to be assigned as medication nurse. b. cooperated with the investigation. c. presented a neat appearance. d. was sociable with peers.

A The nurse intent on diverting drugs for personal use usually attempts to isolate self from peers and may manipulate others to gain access to medications. Appearance often deteriorates, and errors are blamed on others.

A despondent patient says, "Nothing matters anymore." The most appropriate response by the nurse when would be: a. "Are you having thoughts about suicide?" b. "I am not sure I understand what you're saying." c. "Try to stay hopeful. Things usually work out." d. "What used to matter, before the depression?"

A The nurse must make overt what is covert, that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation and tends to respond candidly to candid inquiries. Conveying that one does not understand can increase patient despair or self-loathing (for being ineffectual in communications). "Try to stay hopeful" is a cliché that suggests that staff do not appreciate how truly distressed and despondent the patient is feeling. Encouraging hopefulness and focusing on things the patient used to enjoy both serve as obstacles to the patient's efforts to convey his present feelings and interfere with addressing these feelings.

A college student who attempts suicide by overdose is hospitalized. When the parents are contacted they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

A The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distracters are not clearly described in the scenario.

A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. illusion b. delusion c. hallucinations d. hypnagogic phenomenon

A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

A patient tells a nurse, "I sometimes get into trouble because I make quick decisions and act on them." A therapeutic response would be: a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I'll bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate the outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for 5 days. The patient is now more talkative and shows increased energy on the unit. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient must be supervised 24 hours per day; the patient is still a suicide risk.

An older adult with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items.

A The patient with moderate Alzheimer's disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality.

A patient became severely depressed when the last of her six children moved out of the home 4 months ago. Since then she has neglected to care for herself, sleeps poorly, lost weight, and repeatedly states, "No one cares about me anymore. I'm not worth anything." Upon admission to the unit, the nursing diagnosis Situational low self-esteem related to feelings of abandonment was established. Which would be an appropriate intermediate outcome for this diagnosis? Patient will: a. make one positive comment about self daily by (date). b. agree to antidepressant medication regularly by (date). c. interact with another person for 10 minutes daily by (date). d. identify factors which increased her depression by (date).

A The primary goal of treatment of depression is improved mood, which in turn leads to improvement in other areas of concern such as intake, socialization activity level, and impaired self-esteem. In this case, stating a positive comment about herself would indicate improvement in low self-esteem, and replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. Agreeing to take medication, while perhaps necessary for her treatment and improvement, would not necessarily indicate improvement in self-esteem and would better serve as a short-term indicator, since it would need to precede other expected outcomes. Interacting with others would be an appropriate intermediate goal for impaired socialization, and identifying factors contributing to her depression would be an appropriate short-term indicator.

Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer's disease b. Acquired immunodeficiency syndrome (AIDS)-related dementia c. Wernicke's encephalopathy d. Central anticholinergic syndrome

A The problems are all aspects of the pathophysiologic characteristics of Alzheimer's disease.

A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include? a. Pain assessment techniques for older adults b. Psychosocial stimulation for those who live alone c. Preparation of psychiatric advance directives in the elderly d. Ways to manage disinhibition in elderly persons with dementia

A The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin the assessment. a. "What thoughts do you have about a person's right to take his or her life?" b. "Do you have any risk factors that potentially contribute to suicide?" c. "Do you think you are vulnerable to developing depressed mood?" d. "If you felt suicidal, would you tell someone about your feelings?"

A This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct and may produce responses that may be unclear.

In the emergency department, a patient's vital signs are: BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic overdose. Select the priority outcome. a. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. b. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. c. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields. d. The patient will demonstrate effective coping skills within 1 week of hospitalization. e. The patient will identify community resources for treatment of substance abuse.

A This short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.

The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which reply by the nurse would be most helpful? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications.

A new nurse says to a peer, "My newest patient has schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful? a. "Let's reconsider your plan. Suicide risk is high in patients with schizophrenia." b. "Suicide is a risk for any patient with schizophrenia who uses alcohol or drugs." c. "Patients with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients with schizophrenia."

A Up to 10% of patients with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients with schizophrenia. Patients with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia.

A new nurse mentions to a peer, "My patient has just been diagnosed with schizophrenia. At least I will not have to worry about him being suicidal." The most helpful response by the peer would be: a. "People with schizophrenia are at high risk, especially early in their illness." b. "You will need to assess him further, as anyone can commit suicide." c. "Suicide is a risk for any patient with schizophrenia who uses alcohol or drugs." d. "Yes, they are too disorganized and delusional to be able to hurt themselves."

A Up to 60% of males with schizophrenia attempt suicide, and 10% of patients with schizophrenia die from suicide. The risk is highest in the early years of the illness. Further assessment is indicated, but this statement does not clearly refute the nurse's mistaken belief that psychosis is associated with lower suicide risk. The scenario does not mention substance use; although it would further increase suicide risk, even without substance abuse, persons with schizophrenia are at higher risk. Persons with schizophrenia can be disorganized and delusional, but delusions and hallucinations (especially command hallucinations) can increase suicide risk.

A student nurse caring for a patient with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

A, C, D, F Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self.

A patient with stage 1 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain

B Memory impairment is present and expected in stage 1 Alzheimer's disease. Data are not present to suggest the other diagnoses.

During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent

B Mood is a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.

A patient who has been depressed for the past several months presents in the clinic stating, "I'm at the end of my rope." Which of the following inquiries would be most effective to use for assessing suicide risk? a. "You seem very depressed and stressed. What is that like for you? What sort of feelings are you having when you say that?" b. "Tell me more about what you mean when you say you're at the end of your rope—are you thinking about killing yourself?" c. "Tell me about your family history. Do you have relatives or ancestors who suffered from depression?" d. "Tell me about your depression and being at the end of your rope; what are you thinking and feeling?"

Although broad openings are valuable for eliciting information about a patient's concerns, when the nurse is seeking information about suicide risk, it is important to be candid, specific, and direct. This candidness shows you are concerned and is likely to elicit a more candid response from the patient. Similarly, the more specific the question, the more specific the answer.

The nurse uses the SAD PERSONS scale as he interviews a patient who has expressed suicidal ideation. This tool provides data relevant to: a. mood disturbance. b. suicide potential. c. current stress level. d. level of anxiety.

B The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool is not designed to assess depression itself and does not have appropriate categories to provide information about stress or anxiety.

A staff nurse tells another nurse "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."

B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.

Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken.

B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.

A patient with borderline personality disorder has cut her wrists. The physician orders daily dressing changes for the lacerations. The nurse performing this care should: a. encourage the patient to vent anger and aggression. b. provide care in a matter-of-fact manner. c. be kindly, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.

B A matter-of-fact approach does not provide the patient with inadvertent positive reinforcement for self-injurious behavior. The goal of providing emotional consistency is supported by this approach. All other options provide positive reinforcement of the behavior. Discussion of feelings should occur apart from episodes of self-mutilating behavior and related nursing care. Sympathy is not therapeutic in general; overtures of kindness and concern can evoke fears of abandonment, and even when this is not a concern, can reinforce self-injurious behavior if they are provided during response to self-mutilating behavior.

A patient with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. encourage the patient to express anger. b. provide care in a matter-of-fact manner. c. be very kind, sympathetic, and concerned. d. offer to listen to the patient's feelings about cutting.

B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. All other options provide positive reinforcement of the behavior.

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs.

B A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

Police bring a patient to the emergency department after an automobile accident. The patient is ataxic and has slurred speech and mild confusion. The blood alcohol level is 0.4 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently.

B A nontolerant drinker would be in coma with a blood alcohol level of 0.40 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

A patient with depression repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

B A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, he experiences anxiety, craving, poor concentration, and headache. This scenario describes: a. substance abuse. b. substance dependence. c. substance intoxication. d. recreational use of a social drug.

B Nicotine meets the criteria for a "substance," the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or recreational use of a social drug.

A 78-year-old resident of a skilled nursing facility has hypertension and cardiac disease. This resident is usually alert and oriented but this morning tells the nurse, "My family visited during the night. They brought flowers and candy to me." In reality, the patient's family lives 200 miles away. The nurse should first suspect that the resident: a. may be developing Alzheimer's disease associated with advanced age. b. may have a cognitive impairment associated with medication actions. c. had a stroke and developed sensory perceptual alteration. d. has an alcohol-related cognitive impairment.

B A resident taking medications is at high risk for becoming confused due to medication side effects, drug interactions, and delayed excretion. The nurse should report the event and continue to assess for cognitive impairment. Symptoms of dementia tend to develop slowly but persist over time. The history would alert the nurse to alcohol-related cognitive impairment.

Select the most accurate description of substance dependence. a. Symptoms occur when two or more drugs affecting the central nervous system are used for their additive effects. b. Lack of control over use. Tolerance exists. Withdrawal symptoms occur when intake is reduced or stopped. c. Psychoactive drug use interferes with the action of competing neurotransmitters. d. Taking a combination of drugs to weaken or inhibit the effect of another drug.

B According to the DSM-IV-TR, substance dependence involves lack of control over use as well as tolerance and withdrawal symptoms when intake is reduced or stopped. The distracters describe antagonistic and synergistic effects.

A student nurse visiting a senior center says, "It's depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion." The student is expressing: a. reality. b. ageism. c. empathy. d. vulnerability.

B Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student.

An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: a. form of group therapy led by a psychiatrist." b. self-help group for which the goal is sobriety." c. group that learns about drinking from a group leader." d. network that advocates strong punishment for drunk drivers."

B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

An adolescent whose peer committed suicide attempts suicide himself but is now ready for discharge to outpatient care. Which of the following actions would be most important to accomplish before the discharge? a. Take the patient to a support group for young persons with mood disorders. b. Assure that all guns and medications have been locked or taken off premises. c. Have the patient sign a no-suicide contract agreeing to seek help if in danger. d. Arrange a pass so he can go to his first outpatient session to meet his counselor.

B All of the interventions listed would be reasonable to undertake and could benefit the patient. However, removing potential means for possible future suicide attempts is the priority intervention because it involves safety. Guns in particular should be locked or, better still, removed from the premises because they are highly lethal and are the means most used by males who commit suicide.

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint? a. Dysthymia b. Anhedonia c. Euphoria d. Anergia

B Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means without energy.

A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important? a. Complete a neurological assessment. b. Ask if the patient can hear clearly as the nurse speaks. c. Suggest that the patient lie down in a darkened room for a few minutes. d. Administer medication to relieve the patient's pain before continuing the assessment.

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.

Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

B Both types of patients commonly experience paranoid delusions; thus the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

A patient with depression tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being exceptionally hard on yourself when you imply you are a jinx." d. "What about the good things that happen; are any of them ever your fault?"

B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.

During morning care, a nursing assistant asks a patient with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

B Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

A depressed patient who is taking a tricyclic antidepressant tells the nurse, "I don't think I can keep taking these pills. They make me very dizzy, especially when I stand up." The best nursing response is: a. "That is annoying, but it is something most patients are able to learn to live with as time goes on. You'll get used to the medicine's side effects." b. "The medicine can slow the body's adjustment of blood pressure when changing position; drinking more fluids and changing position slowly can help." c. "Compared to the problems caused by the depression, it seems like a relatively small annoyance to have to put up with." d. "All medicines have side effects, and this one is relatively mild. It could be that your depression is causing you to think negatively about the medicine."

B Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated, change positions slowly, and hold on to bedrails or other secure structures to steady oneself until dizziness subsides. Knowing these facts may be enough to convince the patient to continue the medication. Implying that the side effect should be acceptable, that the patient should adjust to it, or that the patient's concern is a result of the depression itself all ignore the potential for reducing the side effect and its consequences (e.g., fall risk) via patient education.

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "While sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as you can. You will need to provide social protection." d. "Alcohol is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully."

B During recovery, patients identify and use alternative coping mechanisms to reduce reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disease of self-destruction. You will need to observe your spouse's behavior carefully

B During recovery, patients identify and use alternative coping mechanisms to reduce their reliance on alcohol. Physical adaptations must occur. Emotional responses, formerly dulled by alcohol, are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who should be given anticipatory guidance and accurate information.

A nurse reviews vital signs for a patient admitted last night with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings: Admission, 2 AM - 118/78 mm Hg and 72 beats/min 4 AM - 126/80 mm Hg and 76 beats/min 6 AM - 128/82 mm Hg and 72 beats/min 8 AM - 132/88 mm Hg and 80 beats/min 10 AM - 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

B Elevated pulse and blood pressure may indicate impending withdrawal delirium and that additional sedation is warranted. None of the other options takes into account the possible need for sedation. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

A tearful, anxious man comes to the clinic with the chief complaint, "I should be dead." The first task of the nurse conducting the assessment interview is to: a. assess the lethality of his suicide plan. b. establish initial rapport with the patient. c. encourage the expression of anger. d. determine risk factors for suicide.

B Establishing rapport is key to developing a therapeutic relationship, which in turn increases the likelihood of candid and helpful responses to the nurse's assessment. The nurse would then assess lethality and risk factors but not encourage the expression of anger during the assessment phase.

A patient with borderline personality disorder has been making steady progress but one day gets a phone call from her boyfriend, who breaks off their relationship. Although she has not self-injured in over 2 months, she makes repeated lacerations on her forearm. Which statement about this and most maladaptive behaviors seen in personality disorders is most accurate? a. People with personality disorders rarely achieve lasting improvement. b. However dysfunctional, most behavior is the person's best effort to cope. c. People with personality disorders are at the mercy of others' actions. d. What appears to be improvement can be manipulation instead.

B Even when a behavior is maladaptive or ineffective, it usually represents our best effort to cope, given the coping skills and resources available to us at that time. For people with personality disorders, coping overall is usually less effective and more rigid than for other persons, but it too represents each person's best efforts to cope with the circumstances at that moment. Recovery from many medical and psychiatric disorders, including personality disorders, can be slow and involve periods of relapse or regression. However, that does not mean that personality disorders do not improve or that these patients are at the mercy of others' actions. Like everyone else, they can learn to cope and be resilient under stress. What looks like improvement is not necessarily manipulation instead.

Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.

A patient with borderline personality disorder cut her wrists while out on a pass. For future planning, staff should consider that the reason for the self-mutilation is probably related to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. fear of abandonment associated with relationships or increasing autonomy. c. use of projective identification and splitting to bring anxiety to manageable levels. d. a constitutional inability to regulate affect, predisposing to psychic disorganization.

B Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when the patients experience success or growth or begin to develop relationships with others, because these changes increase anxiety and renew fears of abandonment. Research does not indicate that self-injurious behavior is genetic, nor that difficulty regulating affect is constitutional (integral to the person and unchanging) in nature. Although splitting is a frequently demonstrated defense mechanism in borderline personality disorder, projective identification is less common; neither is related to self-injurious behavior.

A disheveled, severely depressed patient with psychomotor retardation has not showered for several days. The nurse should: a. provide rewards when the patient showers and withhold them when he doesn't. b. assist him into the shower, provide soap, and direct him to wash his face first. c. motivate the patient by noting that his body odor is beginning to offend his peers. d. discuss hygiene at the community meeting, without mentioning specific patients.

B Impaired hygiene is common in severe depression. Depressed patients have difficulty organizing tasks involving multiple steps and may avoid them for that reason. They also suffer from anergia (reduced energy) and loss of awareness and interest related to hygiene. It is often necessary for nurses to take an active role in directing the patient into the shower and providing step-by-step instructions to guide the patient and keep him on task. Rewards do not work effectively on people who are anhedonic or feel undeserving (or deserving of punishment). Advising him that he offends his peers would be a disconfirming (nontherapeutic) statement in that it would cause embarrassment and shame, further impairing his self-esteem. Depressed patients are often cognitively disorganized, making it unlikely that they would respond as hoped to generic education about hygiene in a group setting.

A patient being treated for major depression is the CEO of her own business. She has shown significant improvement and is about to be discharged after completing a course of 15 electroconvulsive therapy sessions. She will continue on SSRI medications. The patient has been counseled not to make a major business decision for a month. The rationale for this is that: a. SSRIs may cause confusion in susceptible persons. b. ECT often causes temporary memory impairment. c. Lingering depression makes the patient incompetent. d. The patient needs months to readjust to work pressures.

B Impairment of recent memory is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. SSRIs typically do not cause confusion. The patient's depression has improved, so it is unlikely that her competency is currently affected, and although she may need a period of readjustment on returning to work, this is not the primary reason for counseling against major decisions in the first month back at work.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer's disease was subsequently diagnosed. Which stage of Alzheimer's disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late) the ability to talk and walk are eventually lost and stupor evolves.

A patient who was hospitalized for 2 weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care.

The statement made by the patient during the assessment interview that should alert the nurse to the patient's need for immediate, active intervention is: a. "I am mixed up, but I know I need help." b. "I have no one to turn to, you're my last hope." c. "Why doesn't anyone care anymore?" d. "It's a long, rough road out there, very hard."

B Lack of social support and social isolation increase the suicide risk, and "you're my last hope" suggests that the person is out of options if help does not occur now—a covert expression of suicidal ideation. A willingness to seek help suggests lower risk. "Why doesn't anyone care?" suggests a sense of isolation but does not necessarily indicate a high degree of risk. "It's rough" conveys that the person is experiencing hardship but not necessarily that he is at risk.

A hospitalized, alcohol-dependent patient believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes. b. One-on-one supervision. c. Keep the room dimly lit. d. Force fluids.

B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

Which statement about aging provides the best rationale for focused assessment of elderly patients? a. The elderly are usually socially isolated and lonely. b. Vision, hearing, touch, taste, and smell decline with age. c. The majority of elderly patients have some form of early dementia. d. As people age, thinking becomes more rigid, and learning is impaired.

B Only the key is a true statement. It cues the nurse to carefully assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging.

A nurse instructs a patient taking a drug that inhibits the action of a monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

B Patients taking MAOI-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure.

A patient with major depression says, "No one cares about me anymore. I'm not worth anything." The nurse wants to reinforce positive self-esteem. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you're wearing." d. "You must be feeling better today."

B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as an observation avoid negative interpretations. Saying "You look nice" or "I like your shirt" gives approval (nontherapeutic techniques). Saying "You must be feeling better today" is an assumption, which is nontherapeutic.

A patient with Alzheimer's disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.

B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars.

B Reorientation may seem like arguing to a patient with cognitive deficits and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation.

The nurse caring for a college student who attempted suicide by overdose believes brain biochemical dysfunction contributes to suicidal behavior. The nurse will be better able to plan necessary health teaching if she identifies the probable neurotransmitter alteration of: a. acetylcholine excess. b. serotonin deficiency. c. dopamine excess. d. γ-aminobutyric acid deficiency.

B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. Knowing this, the nurse would understand the rationale for the use of selective serotonin reuptake inhibitors and plan appropriate health teaching. The other neurotransmitter alterations have not been implicated in suicidal behavior.

Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises.

A health care provider writes these new prescriptions for a skilled nursing facility resident: 2 G sodium diet Restraint as needed Limit fluids to 1800 mL daily Continue antihypertensive medication Milk of magnesia 30 mL PO once if no bowel movement for 3 days The nurse should: a. question the fluid restriction. b. question the order for restraint. c. transcribe the prescriptions as written. d. assess the resident's bowel elimination.

B Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other orders would be considered appropriate for implementation.

Which commonality would be most applicable to the patient with a personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.

B Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress.

A severely depressed patient with psychomotor retardation has begun activities therapy. His schedule is: 9 AM, ceramics; 10 AM, exercise group; 11 AM to noon, open; noon, lunch. The nurse creating the patient's schedule should opt to fill the hour block from 11 AM to noon with: a. group therapy. b. a rest period. c. reminiscence group. d. individual counseling.

B Severely depressed patients have anergia (little mental or physical energy) and are readily fatigued. Psychomotor retardation also takes its toll. After 2 hours of activity, the patient may be simply too tired to gain anything from a therapy group. Fatigue can also worsen irritability and depression. The patient should be allowed to rest at intervals and have therapy scheduled later in the day.

The measure that would be considered a form of primary prevention for suicide is: a. psychiatric hospitalization of a suicidal patient. b. referral of a formerly suicidal patient to a support group. c. helping school children learn to manage stress and be resilient. d. suicide precautions for 24 hours for newly admitted patients.

C This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures, and support group referral is a tertiary prevention measure.

Information given to a depressed patient and family when the patient begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy should include the directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 gm daily. d. maintain a tyramine-free diet.

B Some evidence indicates that suicidal ideation may worsen at the beginning of SSRI antidepressant therapy, so close monitoring is necessary, and the patient and family should be directed to report immediately any intensification in suicidal ideation, intent, or plans. SSRI medications do not increase photosensitivity or require dietary tyramine or sodium restrictions.

A patient with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy, and priority information is given to the patient and family. This information should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet.

B Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

A nurse set limits for a patient with a borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was mistaken. You're terrible." This outburst can be assessed as: a. denial. b. splitting. c. reaction formation. d. separation-individuation strategies.

B Splitting involves loving a person and then hating the person; the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is an unconscious motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. Separation-individuation strategies refer to childhood behaviors related to developing independence from the caregiver.

Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol dependence. a. Strongly confrontational b. Empathetic, supportive c. Skeptical, guarded d. Cool, distant

B Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

B The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

Consider these health problems: Lewy body disease, Pick's disease, and Korsakoff's syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia

B The listed health problems are all forms of dementia.

The nurse in the emergency department tells the daughter of a patient that her 86-year-old mother has had a stroke. The daughter tearfully asks the nurse, "Who will take care of me now?" When the nurse explores this query, the daughter mentions that her mother always tells her what job to take, what clothes to buy and wear, and what to have for lunch. The daughter states that she needs someone to direct her and reassure her when she gets anxious. With which personality disorder is this presentation most consistent? a. Histrionic b. Dependent c. Narcissistic d. Borderline

B The main characteristic of dependent personality disorder is a pervasive need to be taken care of that leads to submissive behaviors and fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline

B The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.

A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as the medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers and seeks access to medications. Usually, the person's appearance will deteriorate, and he or she will blame errors on others.

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: 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?"

B The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

An 80-year-old with arthritis has difficulty walking. The patient tells the nurse, "It's awful to be old. Every day is a struggle. No one cares about old people." Select the nurse's best response. a. "Everyone here cares about old people. That's why we work here." b. "It sounds like you're having a difficult time. Tell me about it." c. "Let's not focus on the negative. Tell me something good." d. "You are still able to get around, and your mind is alert."

B The nurse uses empathetic understanding to permit the patient to express frustration and clarify her "struggle" for the nurse. The other options block communication.

In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and daughter in an automobile accident. The patient has no other family, only a few acquaintances in the community. The nurse's priority is to gather additional assessment data to determine whether which nursing diagnosis applies to this patient? a. Spiritual distress related to being angry with God for taking her family b. Risk for suicide related to recent deaths of significant others c. Anxiety related to sudden and abrupt lifestyle changes d. Social isolation related to loss of existing family

B The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient's social isolation is important, but the risk for suicide has higher priority.

A 79-year-old white male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as: a. normal pessimism of the elderly. b. evidence of suicide risk. c. a cry for sympathy. d. normal grieving.

B The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.

A depressed patient repeatedly tells staff that he's evil and that his "insides are rotting" because God is punishing him. What would the priority nursing diagnosis for this patient be? a. Spiritual distress b. Disturbed thought process c. Situational low self-esteem d. Ineffective health maintenance

B The patient is demonstrating delusional thinking suggestive of worthlessness and guilt. The delusional thinking indicates significant cognitive disorganization, potentially placing the patient at risk due to impaired judgment. The cognitive disorganization also interferes with patient learning and understanding and would make it more difficult for the patient to respond to interpersonal therapies. If the issue of impaired thought process is not addressed, the patient will have more difficulty responding to other forms of treatment and may experience harm. Therefore, disturbed thought process is the priority concern in this situation. The other diagnoses do not involve issues of risk and thus are lower priorities.

A patient was admitted last night with a hip fracture sustained while intoxicated. The patient points to the Buck's traction and screams, "Why did you tie me up? Please let me go." The patient is experiencing: a. a delusion. b. an illusion. c. hallucinations. d. codependence.

B The patient is misinterpreting the ropes of the Buck's traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Codependence is an experience of significant others.

A worker is characterized by her co-workers as "painfully shy" and lacking in self-confidence. Her co-workers say she stays in her cubicle all day, never coming out for breaks or lunch. One day after falling on the ice in the parking lot, she goes to the nurse's office, where she apologizes for falling and mentions that she hopes the company will not fire her for being so clumsy. Which nursing approach or response would be most therapeutic? a. Remain professional and a bit detached so as not to arouse suspiciousness on her part. b. Reassure her that many others have fallen at work and not ever been criticized or fired. c. Acknowledge her concerns in a matter-of-fact manner and provide first aid as needed. d. Explain that an incident report about her fall will go to a manager who will contact her.

B The patient manages anxiety by keeping a low profile at work, avoiding situations where others might have any reason to criticize her (or even be aware of her). The fall has interfered with this coping strategy. It is likely she will be highly anxious about the prospect of being criticized and fear that a disciplinary action will follow. Therefore, interventions which reduce her anxiety and help her reframe her fears so they are more realistic are desirable. The best example here is sharing that others have fallen and never been criticized or fired. This patient's presentation does not suggest an inclination to be suspicious of others, and support would be more helpful for her anxiety than detachment or behaving in a matter-of-fact manner that focuses on her physical injuries rather than her emotional concerns. Telling her about the incident report going to a manager who will respond at some unknown point in the future is likely to greatly heighten and extend her anxiety and distress.

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs

B The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. The alcohol is less potent. b. Tolerance has developed. c. Hypomagnesemia has occurred. d. Antagonistic effects are evident.

B Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.

When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. The alcohol is less potent. b. Tolerance develops. c. Antagonistic effects occur. d. Hypomagnesemia develops.

B Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects would account for this change.

What is the priority nursing diagnosis for a patient with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Disturbed sensory perception-auditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping

B Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders rarely have psychotic symptoms. When patients with antisocial personality disorders use denial, they use it effectively. Although ineffective coping applies, the risk for violence is a higher priority.

A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who: a. consumes 1 glass of wine nightly with dinner. b. abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends AA. c. began to drink large amounts of alcohol daily after retirement "to keep my mind off my arthritis." d. drank socially throughout adult life and continues this pattern, saying "I've earned the right to do as I please."

C Alcohol dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.

A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine

C Sedation allows for the safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

When a patient with a personality disorder uses manipulation as a way of getting needs met, the staff agree to use limit setting as an intervention. How does limit setting work to reduce manipulation? a. Limit setting indulges the patient's desire for attention from staff. b. It gives the patient a different concern on which to focus his anger. c. External controls provide security while internal controls are developing. d. When staff limit the patient's behavior, he is no longer anxious about it.

C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls are implemented until the patient is able to develop internal controls (i.e., to control his behavior on his own). Properly implemented, limit setting does not provide the patient with undue attention. Although patients may become angry when limits are set, limits are not designed to draw the focus of a patient's anger off some other target. Limit setting can sometimes reduce patient anxiety but in other cases can temporarily increase it.

When a patient with a personality disorder uses manipulation to get his or her needs met, the staff decides to apply limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patient's wishes so assertiveness will develop. c. External controls are necessary while internal controls are developed. d. Anxiety is reduced when staff members assume responsibility for the patient's behavior.

C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.

What is an appropriate initial outcome for a patient with a personality disorder who frequently manipulates others? The patient will: a. Identify when feeling angry. b. Use manipulation only to get legitimate needs met. c. Acknowledge manipulative behavior when it is called to his or her attention. d. Accept fulfillment of his or her requests within an hour rather than immediately.

C Acknowledging manipulative behavior is an early outcome that paves the way for taking greater responsibility for controlling manipulative behavior at a later time. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The patient will ideally use assertive behavior to promote the fulfillment of legitimate needs. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity and immediacy control.

An indicator that the suicidal patient is exercising suicide self-restraint is: a. adherence to antidepressant therapy. b. agreeing to sign a no-suicide contract. c. disclosing a plan for suicide to staff. d. expressing feelings of hopelessness to the nurse.

C Admitting a plan for suicide to staff is an indicator of self-restraint. By admitting that a plan exists, the patient enables staff to take appropriate measures to prevent the patient from carrying out the plan. Patients may comply with antidepressant therapy and still make suicide attempts and may sign no-suicide contracts, knowing they will make a later suicide attempt. Expressing hopelessness does not indicate suicide self-restraint.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment

C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.

A student has committed suicide. Which statement(s) about those left behind after suicide is accurate? a. A suicide makes survivors more conscious of risk factors and more motivated to reduce risk in themselves and others, leading to a reduced risk of suicide in survivor groups. b. The first few weeks after a suicide are the most difficult and are when survivors are at highest risk; the risk then returns quickly to its pre-suicide level as time passes. c. All survivors are at increased risk, should be assessed for risk at intervals after their loss, and would benefit from ongoing support primary intervention to reduce their risk. d. Speaking of the dead increases the discomfort of surviving loved ones and should generally be avoided in their presence.

C All survivors, both family and peers, are at higher risk of suicide after their loss. Grief, guilt, despair, and modeling all contribute to this risk, as does the isolation that can sometimes follow because of the shame, discomfort, and stigma often associated with suicide. Although consciousness and preventive efforts (e.g., screenings) may increase following a suicide, the overall risk among surviving family members and peers is significantly increased nonetheless. The grief and other factors underlying this increased risk usually lasts for many months or even years, so the risk does not resolve in the weeks after the death. Regular contact to provide support and observe for indicators of risk should be continued for at least a year following the death and for even longer periods around the loved one's birthday, family events, holidays and the anniversary of the loss, or if the risk has continued or independent risk factors exist. Most survivors feel isolated when their loved one is not mentioned. They usually want their loved one to be remembered, and talking about the loss helps reduce the hurt, stigma, and isolation.

Planned interventions for a newly admitted severely depressed patient should include: a. allowing the patient to be alone if he or she prefers. b. encouraging the patient to sleep to regain energy. c. careful, unobtrusive observation around the clock. d. chances to enact a leadership role in the therapeutic milieu.

C Approximately two-thirds of depressed people contemplate suicide. A suicide attempt requires only a short period of unobserved activity. Traditional "every-fifteen-minute checks" allow sufficient time to enact a suicide and are inadequate. Therefore, ongoing direct (but unobtrusive) observation of the depressed patient, at least until such time as his risk for self-harm has been fully assessed, minimizes the chance of self-harm while on the unit. Allowing excessive "alone time" facilitates withdrawal. Rest is important, and while it is not unusual for depressed patients to have a sleep deficit, excessive sleeping is a form of withdrawal, and sleeping at atypical times can further disrupt the patient's circadian rhythm, interfering with sleep in the long run. Impaired cognition, concentration, and self-esteem would make assuming a leadership role unrealistic and frustrating for the patient.

The treatment team discusses a patient diagnosed with paranoid schizophrenia and cannabis abuse who is having increased hallucinations and delusions. The patient has recently used cannabis on a daily basis. To plan effective treatment, the team should: a. provide long-term care for the patient in a residential facility. b. withdraw the patient from cannabis, then treat the schizophrenia. c. consider each diagnosis primary, and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

C Both diagnoses should be considered primary and receive simultaneous treatment. Co-occurring disorders require longer treatment and progress is slower, but treatment may occur in the community.

A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is ordered." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.

C Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

What is the priority intervention for a patient with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints

C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury while hospitalized. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.

When counseling patients with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned.

A student in the Mood Disorders Clinic states that everything he does is wrong and that nothing he tries ever works. Although he has never failed an exam, he believes he will fail the next one. Based on evidence-based research, which of the following interventions would best address a presentation of this type? a. Psychoanalytic therapy b. Desensitization therapy c. Cognitive-behavioral therapy d. Alternative and complementary therapies

C Cognitive-behavioral therapy attempts to alter the patient's dysfunctional beliefs by identifying automatic and/or distorted thinking and then questioning it. This is then followed by rewording or reframing the thought in a more realistic manner. The patient is also taught the connection between thoughts and mood. Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and is at least as effective as medication. Evidence does not support similar effectiveness for the other psychotherapeutic modalities mentioned.

A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

C One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

A patient tells the nurse that he is planning to hire a private detective to follow his wife, who he believes is having an extramarital affair. The patient looks behind the door to be sure no one is eavesdropping and asks the nurse what she did with his medical record after he left. The patient's behaviors are most consistent with a diagnosis of: a. antisocial personality disorder. b. schizoid personality disorder. c. paranoid personality disorder. d. obsessive-compulsive personality disorder.

C DSM-IV-TR criteria for paranoid personality disorder include suspiciousness, lack of trust in others, fear of confiding in others, fear that personal information will be used against the individual, holding grudges, and interpreting remarks as being demeaning or threatening. Suspecting loved ones of infidelity or disloyalty is also a frequent feature in this disorder. The patient with antisocial personality disorder is aggressive, manipulative, and exploitative. The patient with schizoid personality disorder is socially avoidant and reclusive. The patient with obsessive-compulsive personality disorder is a perfectionist, is rigid, and is preoccupied with details and control issues.

When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value? a. Evidence of spasticity or flaccidity b. The patient's level of motor activity c. Medications the patient has taken recently d. Level of preoccupation with somatic symptoms

C Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.

A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia b. paranoid delusions, tactile hallucinations, and panic c. runny nose, yawning, insomnia, and chills d. anxiety, agitation, and aggression

C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, minus the temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

An elderly patient complains bitterly and repetitively about numerous somatic concerns, but he has been examined thoroughly by several different health care providers, and physical examinations suggest that he is in good health. The nurse should suspect that the patient's somatic complaints most likely are: a. indications of a hidden physical illness. b. a maladaptive way of coping with stress. c. indications that he is feeling depressed. d. typical responses to the aches of growing older.

C Elderly persons may have difficulty expressing emotions such as sadness or grief and may express them somatically instead. Somatic complaints may be stress related but are not a coping mechanism per se. No data is offered to support the presence of an undiagnosed medical illness or injury. Although aging processes can produce increasing aches and pains, this patient's presentation of bitter, repetitive somatic complaints and negative physical examinations suggests that a different phenomenon is at work.

A nurse with a history of narcotic abuse became unconscious in the locker room after overdosing. After stabilization, the nurse was transferred to the inpatient psychiatric unit. Which action by nursing staff may be enabling? a. Empathizing when the nurse discusses fears of disciplinary action by the state board of nursing. b. Pointing out that work problems are the result, not the cause, of substance abuse. c. Conveying understanding that pressures associated with nursing practice cause substance abuse. d. Providing health teaching about stress management.

C Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The other options are therapeutic and appropriate.

A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief.

C Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients.

A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.

Symptoms of withdrawal from central nervous system depressants for which the nurse should assess include: a. dilated pupils, tachycardia, elevated blood pressure, elation. b. mood lability, incoordination, fever, drowsiness. c. nausea, vomiting, diaphoresis, anxiety, tremors. d. excessive eating, constipation, headache.

C The symptoms of withdrawal from central nervous system depressants are similar to those of alcohol withdrawal.

Which characteristic of individuals with personality disorders makes it most necessary for staff to schedule frequent meetings? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to evoke interpersonal conflict d. Inability to develop trusting relationships

C Frequent team meetings are held to counteract the effects of the patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.

A 20-year-old economics major became severely depressed after failing two examinations in economics. She cried for 2 hours, then called her parents who live in a neighboring state, planning to ask if she could return home. However, her parents were in Europe. When her roommate went home for the weekend, the patient gave her three expensive sweaters to keep. Later, the dormitory resident assistant returned a book to the patient's room and found her unconscious on the floor, with an empty pill bottle nearby. The patient behavior that provided a clue to the suicide attempt was: a. calling her parents. b. staying in her dorm room. c. giving away her sweaters. d. excessive crying.

C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling her parents would not be a clue in and of itself. Remaining in the dorm would be an expected behavior because the patient had nowhere else to go. Crying does not provide a clue to suicide in and of itself.

A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the patient has nowhere else to go.

When assessing a patient's plan for suicide, the priority areas to consider include: a. patient financial and educational status. b. patient insight into his or her suicidal motivation. c. availability of means and lethality of method. d. quality and availability of patient social support.

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 socioeconomic status, insight, and support systems.

When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

C If a person has definite plans that include choosing a method of suicide readily available, 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 older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patient's glasses and hearing aids. d. Keep the room brightly lit at all times.

C Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering

C In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. Monitors sodium intake and weight daily. b. Wears support stockings and elevates the legs when sitting. c. Consults the pharmacist when selecting over-the-counter medications. d. Can identify foods with high selenium content, which should be avoided.

C Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

A man with severe depression is admitted to the partial hospitalization program for mood disorders after exhibiting unintentional weight loss and refusal to go to work. He does not bathe or shave, sleeps poorly, and repeatedly states: "I'm useless, I'm no good to anyone." Which intervention would be best to include in the patient's initial care plan? a. Involve patient in activities akin to those at his work to restore comfort. b. Reinforce his interest in resuming work attendance when it returns. c. Provide patient with nutrient-dense finger foods and weigh daily. d. Provide activities that involve concentration and fine motor skills.

C In this patient's initial treatment, it is important to focus on basic physiological functioning and safety concerns such as ensuring adequate nutrition. Therefore, interventions focused on basic functioning should be stressed in his initial care plan. Providing finger foods enables easier intake, and nutrient-dense foods require that the patient ingest less food while still maintaining his weight. Severely depressed persons have impaired cognition and would have difficulty with tasks involving concentration or fine motor skills. It is important to choose activities for which the patient would have a high likelihood of success (or a positive experience) in order to reduce failure and reinforcement of negative self-image. Reinforcing an interest in work is desirable but unrealistic for his initial care plan.

A highly suicidal patient who has been hospitalized for 2 weeks committed suicide during the night. The measure that will be helpful to staff and patients having to deal with the event is: a. asking the patient's roommate not to discuss the event with other patients. b. keeping newspapers off the unit and sending the television "out for repair." c. holding a staff meeting to express feelings and plan care for other patients. d. discharging the other patients as quickly as possible to prevent copycat attempts.

C Interventions should be aimed at helping the staff and patients come to terms with the loss and grow as a result of the incident. A psychological postmortem assessment should be conducted by staff. A community meeting should be scheduled to inform patients and encourage them to share their feelings and responses. Staff should provide additional support and reassurance to patients and should seek opportunities for peer support and clinical supervision. Efforts to reduce exposure to information about the death would reduce trust, prevent opportunities to help survivors cope, and likely prove ineffective, since such news can almost never be contained. Rushing the discharge of surviving patients would be unsafe and unethical.

A nurse reports to the interdisciplinary team that a patient with an antisocial personality disorder lies to other patients, verbally abuses a patient with dementia, and flatters the primary nurse. This patient is detached and superficial during counseling sessions. Which behavior most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention. The other concerns should be addressed during therapeutic encounters.

The nurse reports to the interdisciplinary team that an antisocial patient lies to other patients, verbally abuses a patient with Alzheimer's disease, flatters his primary nurse, and is detached and superficial during counseling sessions. Which behavior should be the priority focus of limit setting? a. Lying to other patients b. Flattering the nursing staff c. Verbally abusing other patients d. Superficiality during counseling

C Limits must be set in areas in which the patient's behavior affects the rights or safety of others. Limiting verbal abuse of another patient is thus the priority intervention. The other concerns should be addressed during therapeutic encounters but are lesser priorities.

The most challenging nursing intervention with patients with personality disorders who use manipulation to get their needs met is: a. supporting behavioral change. b. monitoring suicide attempts. c. maintaining consistent limits. d. using aversive therapy.

C Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan; positive reinforcement strategies for acceptable behavior are more effective than aversive techniques.

A nurse administers medications to four patients with Alzheimer's disease. Which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne)

C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance intoxication c. Substance dependence d. Recreational use of a social drug

C Nicotine meets the criteria for a substance, the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

The characteristic in individuals with personality disorders that makes it most necessary for staff to schedule frequent meetings is: a. flexibility and unconventional responses to stress. b. a desire to achieve emotional intimacy with staff. c. a tendency to evoke countertransference and conflict. d. an impaired ability to develop trusting relationships.

C One feature shared among the many personality disorders is an impaired or maladaptive style of relating to others. Another such shared factor is a tendency to rely on maladaptive coping mechanisms (such as splitting) to deal with anxiety. Those factors tend to stir strong emotional responses in staff, leading to countertransference responses (e.g., anger toward the patient), a loss of objectivity, reduced ability to be therapeutic, and possibly staff burnout. Staff meetings are one way to increase awareness of these dynamics and deal with them constructively as a group. Patients with personality disorder tend to be inflexible, demonstrate maladaptive responses to stress, and are unable to develop true intimacy with others and trusting relationships; some seek to avoid intimacy. The problem with trust exists but is not the characteristic that requires frequent staff meetings.

In clinical supervision, the nurse caring for the patient with a paranoid personality disorder tells the advanced practice nurse, "I tried being caring and empathetic, but the patient just kept telling me to stay away." Which response by the advanced practice nurse would be best? a. "Acting somewhat cynical and aloof, like they do, will make it easier for paranoid persons to bond with you over time. That, plus humor." b. "You may be trying too hard too soon. Back off, give him some time to get used to you, then try your caring and empathetic approach again." c. "Mistrustful people do not bond as others do, so first it's important to be realistic. Second, a neutral yet courteous approach will work better." d. "You are on the right track, but give it more time. Actively conveying empathy and care will work, but paranoid persons respond more slowly."

C Paranoid persons rarely bond with others in the way that most people do, and efforts to achieve this are counterproductive. Therefore, it is essential to understand the perspective of the patient and develop realistic expectations regarding the nurse-patient relationship. A detached, neutral, straightforward, and courteous approach is most effective. Overt expressions of caring, tenderness and other emotions which are not within the repertoire of the paranoid person tend to increase their suspiciousness. Acting in the manner of the patient (e.g., being mistrusting or cynical yourself) is never appropriate; if the patient believes he is being mimicked, it will increase his mistrust and drive him further away.

Discharge planning begins for an elderly patient hospitalized for 2 weeks with major depression. The patient needs ongoing assessment, socialization opportunities, and education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient. a. Behavioral health home care b. A skilled nursing facility c. Partial hospitalization d. A halfway house

C Partial hospitalization would provide the services the patient needs and give supervision and meals to the patient while the daughter is at work. Home care would not provide socialization. The patient does not need the intensity of a skilled nursing facility. A halfway house provides 24-hour care and usually expects involvement in off-campus programs.

Consider these comments to three different nurses by a patient with an antisocial personality disorder: "You're a better nurse than the day shift nurse said you were"; "Another nurse said you don't do your job right"; "You think you're perfect, but I've seen you make three mistakes." Collectively, these interactions can be assessed as: a. Seductive b. Detached c. Manipulative d. Guilt producing

C Patients manipulate and control staff members in various ways. By keeping staff members off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evidenced in the comments.

The nurse who assesses a patient previously diagnosed as having paranoid personality disorder is most likely to describe the patient as: a. superficially charming. b. intense and impulsive. c. guarded and distant. d. friendly and open.

C Patients with paranoid personality disorder are mistrustful of others. They expect to be exploited or wronged by others and are wary; as a result, they remain apart from others to increase their sense of security. Patients with antisocial personality disorder may display superficial charm, but paranoid persons usually seem cold and aloof and would not seem friendly or open. Patients with borderline personality disorder are intense and impulsive, whereas patients with paranoid personality disorder tend to be controlled and superficial.

An appropriate outcome for a patient with a personality disorder and a nursing diagnosis of Ineffective coping as evidenced by use of manipulation would be that the patient will: _______. a. refrain from manipulative behavior at all times b. use manipulation only to get legitimate needs met c. acknowledge manipulative behavior when it is pointed out d. identify when he is experiencing feelings of anger

C People who are manipulative tend to use manipulation so regularly that it becomes almost an automatic, unconscious response. Being able to recognize or acknowledge when their behavior is manipulative is the first step to replacing manipulation with more adaptive ways of meeting one's needs, paving the way for taking greater responsibility for controlling manipulative behavior. Most people are at least occasionally manipulative, so a complete absence of manipulative behavior would be an unrealistic outcome expectation. Manipulation is maladaptive whether used to meet "legitimate" needs or illegitimate needs. Identifying anger would be helpful for managing maladaptive responses to that emotion but not for manipulation.

A physical therapist recently convicted of multiple counts of Medicare fraud is brought to the emergency department after taking an overdose of sedatives. He tells the nurse, "Sure I overbilled. Why not? Everybody takes advantage of the government. They have too many rules. No one can abide by all of them." These statements can be assessed as showing: a. glibness and charm. b. superficial remorse. c. lack of guilt feelings. d. excessive suspiciousness.

C Rationalization is being used to explain behavior and deny wrongdoing. The patient is not exhibiting regret or remorse, even superficially. A person who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The patient's remarks do not seem designed to use charm to deflect negative consequences, and he is not glib about his situation.

Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

C The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

A woman with a history of several suicide attempts by overdose is found to have recurrent major depression. Given this patient's history and diagnosis, which of the following antidepressant medications would the nurse expect to be ordered? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Desipramine (Norpramin), a stimulating tricyclic medication c. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

C Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that her medication be as safe as possible in case she takes an overdose of her prescribed medication.

Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "I know what you're up to; you're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

Which nursing strategy leads patients to respond more positivity to limit setting? a. Confront the patient with the inappropriateness of the behavior. b. Explore with the patient the underlying dynamics of the behavior. c. Reflect back to the patient an understanding of the patient's distress. d. State clear disapproval of the behavior, and support its consequences.

C Setting limits is better accepted by patients if staff first use empathetic mirroring without making a value judgment. Confrontation, while sometimes an appropriate nursing response, does not enhance the effectiveness of limit setting; neither does exploring the underlying causes of maladaptive behavior. Conveying disapproval is rarely therapeutic in general and does not enhance limit setting; it would tend instead to increase patient resistance and impede the therapeutic relationship.

Which intervention is appropriate to use for patients with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.

C Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.

A woman became severely depressed when the last of her six children moved out of the home 4 months ago. She has withdrawn from others, neglected to care for herself, lost weight, and repeatedly states, "No one cares about me anymore." Before the onset of symptoms she had been gregarious, a meticulous housekeeper, was neatly groomed, and often participated in community activities. Upon admission to the mental health unit, the patient repeatedly tells nursing staff, "No one cares about me. I'm worthless." Which response by the nurse would be most therapeutic? a. "I care about you, and I want to try to help you get better again soon." b. "Things will look brighter soon. Everyone feels down once in a while." c. "It is difficult for others to care when you say negative things over and over." d. "I'll sit with you 10 minutes now, and again during lunch, and at 2:30 PM."

C Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a therapeutic relationship. It also helps counter the withdrawal often seen in depression. Setting definite times for contacts and keeping the appointments shows reliability on the part of the nurse, an element that fosters trust building. Profoundly depressed persons whose self-image is very negative have difficulty accepting that others could care and would tend to believe a nurse who indicates she cares is insincere. "Things will look brighter" is trite and a cliché and is also difficult for a profoundly depressed person to imagine and accept. The patient is essentially unable to say positive things at this point, so pointing out that her behavior is causing others to reject her tends to worsen her self-esteem rather than help her change. Also, it is premature to use confrontation during the initial phase of the nurse-patient relationship.

Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Completing a psychologic postmortem assessment c. Attending a self-help group for survivors d. Contracting for two sessions of group therapy

C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychologic postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide.

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol-withdrawal delirium. d. is having an acute psychosis.

C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol-withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.

C Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.

A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."

C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, "I am not going to harm myself, I am going to kill myself," or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

As a nurse prepares to administer a medication to a patient with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, as well as to prevent splitting other staff members. "Why" questions are not therapeutic.

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield. Oral hygiene is poor in methamphetamine abusers.

C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource.

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

C The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

A patient with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, "I'm feeling empty and want to cut myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level.

C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that reduces the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention; sedation may reduce the patient's ability to weigh alternatives to mutilating behavior.

A patient with borderline personality disorder has been hospitalized several times after self-injurious behavior and suicide attempts. The patient has entered dialectical behavior therapy on an outpatient basis. During therapy, the advanced practice nurse has been counseling her regarding self-harm behavior management. Today the patient called the nurse and reported "feeling empty and anxious" and wants to cut herself. Which response would best help in this situation? a. Arrange for an emergency admission to a crisis unit. b. Arrange for an emergency admission to an inpatient unit. c. Assist the patient to identify and choose a coping strategy. d. Advise the patient to take an anxiolytic, then go to sleep.

C The patient has responded appropriately to the urge to harm herself by calling a helping individual. The nurse can assist the patient to choose an alternative to self-injury. Except when the patient is judged to be at risk of suicide as well, hospital or crisis center admissions are generally discouraged in favor of guiding the patient to use internal controls to manage urges to self-injure. This is designed to minimize dependence on hospitalization for safety and promote independence and adaptive coping. Taking a sedative and going to sleep should not be the first-line intervention, because sedation may reduce the patient's ability to weigh alternatives to mutilating behavior, and using medications to deal with stress (especially in the absence of other adaptive coping alternatives such as relaxation exercises) could increase the risk of drug abuse or dependence.

A patient being treated for depression has been taking 300 mg amitriptyline (Elavil) daily for nearly a year. She calls her case manager at the mental health clinic, stating she stopped taking her antidepressant 2 days ago and has developed something like the "flu," with cold sweats, nausea, a rapid heartbeat, terrible nightmares when she sleeps, but no other symptoms. How should the nurse respond? a. Advise her to go to the nearest emergency department for an evaluation. b. Tell her to take two aspirin, drink plenty of fluids, and call her family doctor. c. Explain it may be withdrawal; tell her to take one Elavil and contact her doctor. d. Direct her to take the medicine every other day for 2 weeks, then stop.

C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms, and discussing her plans with the physician will allow her to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, so the ER is not indicated. The situation is not "normal"; she is likely experiencing withdrawal and is also at risk of worsening or triggering her depression if she stops her medication, so the decision should be made in collaboration with a mental health professional. Aspirin would have no benefit in this situation. Taking the medication every other day would reduce the drug levels she is exposed to, but not in a gradual way; tapering the dosage gradually is needed instead.

Which statement by a patient with borderline personality disorder best indicates the treatment plan is helping? a. "I think you are the best nurse on the unit." b. "I hate my doctor. He never gives me what I ask for." c. "I feel empty and want to cut myself, so I called you." d. "I'm never going to get high on drugs again."

C The patient's seeking a staff member when distressed, instead of impulsively self-mutilating, shows that the patient has adopted an adaptive coping strategy. "You're the best nurse" demonstrates idealization, which is a symptom of the disorder and not a sign of improvement; the same is true of devaluing one's doctor. "I'm never going to use drugs" is a statement of a goal. It may be the patient's intention, but unless the patient demonstrates adaptive coping and sobriety-related behaviors, it is not necessarily an indication of progress.

A patient's employment is terminated and major depression results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

C The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to lead to other diagnoses.

A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

C The symptoms given in the question are consistent with narcotic withdrawal. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

The admission note indicates a patient with depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

C, D, E Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is the lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

A staff nurse tells another nurse, "I just used the SAD PERSONS scale to evaluate a man who sometimes thinks about suicide; his score was 8. I'm wondering if I should send him home after arranging for follow-up." The best reply by the second nurse would be: a. "That would seem appropriate, but I'd consult the on-call resident first." b. "Be sure he is followed up closely; he may require hospitalization later on." c. "I think you should consider hospitalization just to be safe." d. "A score of 7 or higher usually requires immediate hospitalization."

D A SAD PERSONS scale score of 0 to 2 suggests home care with follow-up. A score of 3 to 4 calls for close follow-up and possible hospitalization. A score of 5 to 6 requires the nurse to strongly consider hospitalization, and a score of 7 or higher calls for hospitalization.

Which environmental adjustment should the nurse make for a patient with delirium and perceptual alterations? a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

D A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

When told that he is scheduled to interview a patient with narcissistic personality disorder, the nurse can anticipate the assessment findings will include the following: a. charm, drama, seductiveness, and admiration seeking. b. preoccupation with minute details and perfectionism. c. difficulty being alone, indecisiveness, and submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

D According to the DSM-IV-TR, person with narcissistic personality disorder would have an exalted opinion of themselves, possess a sense of entitlement, and believe their needs should come first. A patient with histrionic personality disorder would be charming, seductive, and seek admiration. An individual with obsessive-compulsive personality disorder would demonstrate rigidity and perfectionism. Indecisiveness, submissiveness, and intolerance for being alone would characterize an individual with dependent personality disorder.

When preparing to interview a patient with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

D According to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR), the characteristics of grandiosity, self-importance, and a sense of entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are observed in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are observed in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

An advance directive gives valid direction to health care givers when a patient: a. has cancer. b. is diagnosed with Parkinson's disease. c. with amyotrophic lateral sclerosis is unable to speak. d. is unable to make decisions for self because of illness.

D Advance directives are invoked when patients are unable to make decisions for themselves. A diagnosis of cancer or Parkinson's disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.

A patient with stage 2 Alzheimer's disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality b. aphasia c. apraxia d. agnosia

D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

An alcohol-dependent patient was hospitalized at 4 AM on Saturday. The patient's last drink was at 2 AM. When would the nurse expect withdrawal symptoms to peak then disappear or progress to delirium? a. Between 8 AM and 10 AM Saturday b. Between 10 AM and 4 PM Saturday c. Between 4 PM Saturday and 4 AM Sunday d. Between 2 AM Sunday and 2 AM Monday

D Alcohol withdrawal usually begins 6 to 8 hours after cessation or marked reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

A depressed patient is receiving imipramine (Tofranil) 300 mg daily. Which side effect requires seeking medical attention? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

D All the side effects mentioned are the result of the anticholinergic effects of the drug. Of these, only urinary retention warrants immediate medical attention. Dry mouth, blurred vision, and nasal congestion do not usually develop into serious medical concerns. However, urinary retention can lead to medical complications and intense pain, can be reduced via medication and other interventions, and requires prompt medical intervention.

A patient with depression is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A depressed patient does not converse except when addressed, and then only in monosyllables. Which response by the nurse is likely to be most helpful? a. "Can you tell me how you're feeling today?" b. "What would you like to talk about?" c. "It would be helpful if you talked more." d. "It seems rather cold in here today."

D Alogia or poverty of speech is common in severe depression and other mental health disorders. Making observations about neutral topics such as the environment draws the patient into the reality around him in a nonthreatening way but places no burdensome expectations for answers on the patient. It also helps to convey interest in the patient and helps to build rapport. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Decision making is often impaired in depression, so asking the patient what he wants to talk about burdens the patient with a task (decision making) likely to frustrate him because he does not want to talk at all. Telling the patient that more talking is desirable places a burden of unrealistic expectations on the patient; this can increase feelings of guilt, frustration, or worthlessness.

A student nurse working with a depressed patient finds herself becoming angry with the patient when he responds slowly or not at all to her efforts to improve his mood. Which explanation most likely explains her emotional response? a. The majority of depressed persons respond only partially to treatment interventions. b. This depressed patient is responding more slowly than most, leading to frustration. c. Depressed patients are often resistant to treatment and a source of frustration to staff. d. Staff can have unrealistic expectations, believing depressed people should "cheer up."

D Although it is true that depressed patients sometimes seem to reject the overtures of staff and seem to resist change despite the nurse's best efforts, the usual cause of negative emotional responses in staff are the staff's own unrealistic expectations. Nursing staff may expect the patient to respond more readily than the patient's depression allows; or they may believe that because the patient is lucid and coherent, he should respond readily and well to verbal interventions. Nurses may also hold unrealistic expectations of themselves, believing that they understand depression because they have been sad themselves and believe their own experiences will be comparable to the patient's (and that what would have been helpful to them will be sufficient to benefit patients as well). However, nursing staff sometimes underestimate how much the depression is affecting the patient's cognition, reasoning, and other higher neurological functions, and when such factors limit the patient's responsiveness, the nurse may experience feelings of anxiety, frustration, incompetence, and even helplessness as a result. Supervision can help the nurse develop realistic expectations for both patient and self. The majority of persons with depression respond well to treatment, showing significant improvement in mood and functioning. It is unlikely that this particular patient is exceptional in failing to respond directly and rapidly to staff's interventions, as most patients improve rather slowly. Depressed patients may resist treatment efforts, but this is not typical of depressed persons.

A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you've been drinking."

D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment.

A recently divorced man with severe depression exhibits poor sleep and impaired concentration, leading him to function poorly at work. Inattention to hygiene and irritability with others aggravate problems at work. Co-workers do not recognize that he is depressed and instead assume his behavioral changes are due to drug abuse. One day he is fired. Work had been his one remaining source of self-worth. The man presents at the emergency room seeking medication to help him sleep. Which of the following responses would be most important for the triage nurse to take at this time? a. "Have you considered seeking treatment for the depression itself?" b. "Tell me what you have already been trying to help improve your sleep." c. "We usually don't prescribe sleep medications in the emergency room." d. "You said you are depressed; have you thought about harming yourself?"

D Approximately two-thirds of depressed people contemplate suicide. Depressed patients who exhibit feelings of worthlessness are at higher risk. Significant losses (divorce and loss of job) and depressed mood are major risk factors for suicide. Suicide should be directly assessed. Seeking further information about his sleep habits and exploring treatment options related to depression are desirable but are not as high a priority at this time as assessing possible risk to self. Advising him that sleep medications are not provided by the emergency room could be seen as further rejection and could lead the patient to terminate the assessment prematurely.

A depressed patient tells the nurse, "The bad things that happen are always my fault." How should the nurse respond to assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "You are being exceptionally hard on yourself when you imply you are a jinx." c. "What about the good things that happen; are any of those ever your fault?" d. "Let's look at one bad thing that happened to see if another explanation exists."

D By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it to a more accurate representation of fact. Casting doubt, while helpful, does not require the patient to evaluate or reframe the statement; refuting the patient's beliefs so directly could also reduce her comfort with the nurse. Noting that the patient is hard on herself reflects an accurate assessment but does not require the patient to evaluate or reframe the statement. Focusing on "good things" shifts the focus slightly and would probably elicit a "no" from the patient; it would be less likely to guide the patient to reconsider the negative distortions in her thinking.

An adolescent who attempted suicide and was admitted to an inpatient mental health unit had been assessed as being at high risk of self-harm, but he has shown improvement. His doctor is now considering discharge and asks the nurse's opinion. Which of the following observations most reliably indicates that he may be ready for discharge to outpatient care? a. He denies that suicide ideation and intent are present. b. His family agrees to observe him closely at home. c. His SAD PERSONS score has gone from a 4 to a 2. d. He focuses on problem solving and hope for the future.

D Demonstrating effective problem-solving abilities and demonstrating hopefulness and a future orientation (looking forward to what lies ahead) are indicators that the internal turmoil underlying suicide risk is resolving. Denial of suicide ideation and intent may or may not be genuine; patients sometimes deny risk quite convincingly to evade treatment or precautions and resume their efforts to commit suicide. Although his family's willingness to monitor him closely at home will be helpful, it does not mean that the patient himself is ready for discharge. A SAD PERSON score, or any similar rating score, is not in and of itself sufficiently reliable in an individual case to determine that a person is safe. Such assessments are screening tools designed to determine what response should be made at the beginning of treatment, not when a person is safe to discharge.

During assessment, the nurse is most likely to find the attitude of the depressed patient toward his illness to be: a. "It's just a matter of time and I'll be well." b. "I think the medicine will help in time." c. "I can fight this, I don't have to be depressed." d. "It's the way I am, I deserve to be this way."

D Depressed patients feel worthless and often believe they deserve to have "bad" things happen. Depressed patients usually feel hopeless and helpless and lack optimism.

A woman became severely depressed when the last of her six children moved out of the home 4 months ago. Since then she has neglected to care for herself, sleeps poorly, lost weight, and repeatedly states, "No one cares about me anymore. I'm worthless." After hospitalization, the nursing diagnosis of situational low self-esteem related to feelings of abandonment was identified. The nurse wishes to reinforce the patient's self-esteem by acknowledging the improvement in her personal appearance. She's wearing a new dress and has combed her hair. The most appropriate remark would be: a. "You look very nice this morning, Mrs. J." b. "I like the dress you're wearing, it's very pretty." c. "What brought about this glamorous transformation?" d. "You've combed your hair and are wearing a new dress."

D Depressed patients usually see the negative side of things, even in positive comments. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other dress." People who do not feel they are attractive may have difficulty trusting others who compliment them, thinking that they are insincere; this can reduce trust in the therapeutic relationship. Neutral comments such as acknowledging the positive changes reinforce the desired behaviors while avoiding negative interpretations. Depressed persons usually have an impaired ability to appreciate humor, so attempts to use humor would not be therapeutic during the initial phase of treatment.

A patient with a history of heart failure is being assessed by the admitting nurse. Which of the following inquiries by the nurse reflects the research on the connection between heart disease and mental health? a. "People with heart disease sometimes have nightmares. How do you sleep?" b. "Heart failure can be frightening. Do you find yourself feeling fearful or worried?" c. "Tell me, have you noticed any problems with your memory and concentration?" d. "Heart failure and depression seem to be related. Tell me about your moods lately."

D Depression has been shown to worsen heart failure, and a variety of cardiac disorders appear to cause depression in some patients. Although anxiety often accompanies any serious medical illness, the special connection between depression and cardiac disease makes this depression the mental health issue meriting special attention in cardiac patients. Heart disease does not have a specific relationship to nightmares.

The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on: a. monitoring for the return of the capacity for full range of motion. b. assessing the degree of accumulating memory impairment. c. making positive comments while the patient is more receptive. d. assessing the level of consciousness and normal body functions.

D During the immediate posttreatment period, the patient is recovering from general anesthesia, hence the need to reestablish and support physiological stability. This includes monitoring the level of consciousness and bodily functions such as vital signs and elimination. Range of motion is unlikely to be affected by ECT and is not a priority. Assessing memory loss immediately after ECT is inappropriate because the patient may be confused. Patients are not more suggestible as a result of ECT.

A patient tells a nurse, "The others won't give me my pain meds early, but you are more understanding, you know what it's like to be in pain, and you don't want to see your patients suffer. Could you find a way to get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," then ignore subsequent requests for early meds. b. "I'll have to check with your doctor about that; I will get back to you after I do." c. "It would be unsafe to give the medicine early; none of us will do that." d. "I understand that you have pain, but giving medicine too soon would not be safe."

D Empathetic mirroring, wherein the nurse reflects back to the patient an understanding of the patient's distress or situation in a neutral manner that does not judge it, helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic, but they lack the empathetic mirroring component that tends to elicit a more positive response from the patient.

A patient with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. The cause of the self-mutilation is probably related to: a. inherited disorder that manifests itself as an incapacity to tolerate stress b. use of projective identification and splitting to bring anxiety to manageable levels c. constitutional inability to regulate affect, predisposing to psychic disorganization d. fear of abandonment associated with progress toward autonomy and independence

D Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.

A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced b. dependent on alcohol c. healthy but underweight d. microcephalic and cognitively impaired

D Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distracters.

When assessing a patient who ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.

D Flunitrazepam is also known as the "date rape drug" because it produces disinhibition and relaxation of voluntary muscles as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly seen after use of this drug.

When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia b. hypothermia c. hallucinations d. anterograde amnesia

D Flunitrazepam is also known as the date rape drug; it produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate glandD

D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

A patient with paranoid personality disorder is noted to sit alone in a corner of the unit living room. When anyone approaches, the patient is haughty or simply ignores the other person. When staff invite her to join an activity, she tells them, "I do not care to be with people who do not like me." A nursing diagnosis that should be considered is: a. splitting. b. activity intolerance. c. powerlessness. d. impaired social interaction.

D Impaired social interaction is a state in which an individual participates in an insufficient (or excessive) quantity or quality of social exchange. A defining characteristic is dysfunctional interaction with others. The patient's suspiciousness, rigidity, and distortions of reality related to projection are likely responsible in this case. Splitting, powerlessness, and activity intolerance are not evident in this scenario.

For which behavior(s) would limit setting be most essential? a. A patient clings to the nurse and asks for advice about inconsequential matters. b. A woman is flirtatious and provocative toward staff members of the opposite sex. c. An elderly man displays hypervigilance and refuses to attend unit activities. d. A young woman urges a suspicious patient to hit anyone who stares at him.

D In urging a paranoid patient to strike anyone who stares at him, the patient is being manipulative, trying to get another patient to act violently while staying "innocent" of actual violence herself. Because manipulation violates the rights of others, limit setting is absolutely necessary. It would be appropriate to set limits relative to any significantly inappropriate behavior, but the highest priority here would be behavior which endangers others, such as enticing the paranoid person to strike anyone who stares at him. Setting limits on sexually provocative behavior would be appropriate but a lower priority than potentially assaultive behavior. Clingy behavior and nonadherence to treatment are not priorities, and interventions other than limit setting would likely be more appropriate.

Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Perforated nasal septum and hypertension b. Drowsiness, euphoria, and constipation c. Pinpoint pupils and respiratory rate of 12 breaths per minute d. Confusion, mouth ulcers, and ataxia

D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid use.

A new nurse asks, "My elderly patient has Lewy Body Disease. What should I do about assessing for pain?" Select the best response from the nurse manager. a. "Ask the patient's family if they think the patient is experiencing pain." b. "Pain is diminished by dementia. Focus your assessment on the patient's mental status." c. "Use a visual analog scale to help the patient determine the presence of pain and its severity." d. "There are special scales for assessing persons with dementia. Let's review how to use them."

D Lewy Body Disease is a form of dementia. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.

Which beverage should the nurse offer to a patient with depression who refuses solid food? a. Tomato juice b. Orange juice c. Hot tea d. Milk

D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." Which defense mechanism is evident? a. Rationalization b. Introjection c. Projection d. Denial

D Minimizing one's drinking is a form of denial of alcoholism. The patient's own description indicates that "social drinking" is not an accurate name for the behavior. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one's own system.

Which medication to maintain abstinence would most likely be prescribed for patients with either alcoholism or opioid addiction? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)

D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)

D Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids; because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

A nurse worked with a patient with major depression who displayed severely withdrawn behavior and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.

D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become overinvolved with patients with depression because of the patient's resistance. Guilt and despair might be observed when the nurse experiences patient feelings because of empathy. Interest is possible but not the most likely result.

When a patient comes to an outpatient appointment, a nurse smells alcohol. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you have been drinking."

D One cannot conduct meaningful therapy with an intoxicated patient. The nurse is setting reasonable limits. The patient should be taken or escorted home and then make another appointment.

A patient with antisocial personality disorder tells Nurse A, "You're a much better nurse than Nurse B said you were." The patient tells Nurse B, "Nurse A's upset with you for some reason." To Nurse C the patient states, "You'd like to think you're perfect, but I've seen three of your mistakes this morning." These comments can best be assessed as: a. seductive. b. detached. c. guilt producing. d. manipulative.

D Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the antisocial person is left to operate as he or she pleases. Seductive behavior uses sexuality to achieve one's aims and is not evident here. The patient is interacting actively rather than detaching from those around him. Guilt is not overtly evident, although Nurse C might experience guilt in response to his criticism.

A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

D Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

To plan effective interventions, the nurse should understand that the underlying reason a patient with paranoid personality disorder is so critical of others probably lies in the patient's: a. need to control all aspects of the world around him. b. use of intellectualization to protect against anxiety. c. inflexible view of the environment and the people in it. d. projection of blame for his own shortcomings onto others.

D Projection allows the patient to disown negative feelings about himself and see these feelings as being directed at him from an outside source (the nurse) instead. The patient then can justifiably retaliate by being hostile to the nurse. To realize that the patient is accusing the nurse of his or her own faults makes the criticism easier to manage without retaliation. The other options are not related to the dynamics of critical behaviors on the part of the patient.

When suicidal patients are admitted to a hospital, objects that can easily be used for self-harm are removed from their possession. The rationale for this intervention is that: a. the patient's environment must be made completely safe. b. psychiatric patients cannot be trusted with dangerous objects. c. it shows staff are alert, so the patient won't even try suicide. d. removing harmful objects conveys concern and reduces risk.

D Promoting patient safety is a priority concern, and all reasonable efforts should be made to minimize risk to target patients and the patient population in general. To maintain a safe milieu, harmful objects are confiscated and only available for use only under supervision. No environment can be made completely safe; risk can only be reduced or minimized. Although some patients can be trusted not to harm themselves or others, some cannot. Searches do suggest that staff are alert to dangers but can have the opposite effect of making an attempt seem pointless. They can motivate the patient to be even more creative in efforts at self-harm.

A physical therapist recently convicted of multiple counts of Medicare fraud says to a nurse, "Sure I overbilled. Why not? Everyone takes advantage of the government. They have so many rules; no one can follow them." These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not exhibit anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust or concern that others are determined to cause harm is not evident.

Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.

D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

D Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

A patient with antisocial behavior was treated several times for substance dependence. Each time, the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

D Residential programs and therapeutic communities help a patient change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

A college student who attempted suicide by overdose was treated in the emergency department. Because the patient lives in the dorm and her roommate and her parents are away, the decision was made to hospitalize her. The nursing diagnosis of highest priority would be: a. Powerlessness. b. Social isolation. c. Compromised family coping. d. Risk for self-directed violence.

D Risk for self-directed violence is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

Which statement made by a patient with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I hate my doctor for not giving me what I ask for." d. "I felt empty and wanted to cut myself, so I called you."

D Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "The staff here cares about you and wants to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point.

The most helpful response for the nurse to make when a patient being treated as an outpatient states, "I am considering committing suicide" is: a. "I am glad you shared this. There is nothing to worry about. We will work it out." b. "We need to talk more about the things you have to live for, the good in life." c. "I think you should admit yourself to the hospital to get help with this." d. "Bringing this up is a very positive action on your part. Tell me more."

D Stating that the disclosure is a positive step reinforces and validates the patient for making an adaptive response rather than acting on the suicidal impulse. It also encourages the patient to elaborate and provide more specific data on which to assess the patient. It gives neither advice nor false reassurance. It does not involve trite clichés ("the things you have to live for, the good in life") that tend to suggest the patient is wrong or bad for having suicidal ideation, which in turn reduce the patient's willingness to be honest about the ideation.

A person attempts suicide by overdose, is treated in the emergency department, and is then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

A patient who has been taking fluoxetine (Prozac) 60 mg daily for the past 6 months tells the nurse at the medication follow-up clinic that he is considering stopping the Prozac. He states his mood is fine, and now that he is living normally, his wife is concerned that he has no sex drive. Which response would be best? a. "Without the medicine the depression will likely return; you and your wife will need to adjust to the sexual side effects." b. "If we switch your medication time to the morning, the sexual side effects will be worn off in time for evening sexual activity." c. "The problem is not likely due to the medicine. Often the depression itself, even after it improves, continues to dampen sex drive." d. "Without an antidepressant, the depression is more likely to reoccur, but there are other medications that do not interfere so much with sex."

D The SSRI medications vary in how much they affect sexual function; some have a less negative impact than others and could reduce this problem for the patient and his spouse. Non-SSRI antidepressants might also allow continued treatment of the patient's depression without sexual side effects. Advising the patient to learn to accept the side effects overlooks potential solutions that could reduce the problem and increases the likelihood that the patient will simply become nonadherent to his medication. Changing the medication time will not help the sexual side effects. Although depression often reduces sex drive, in this case the depression has lifted, so the medication is more likely the cause of the sexual problem.

A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"

D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

A patient remanded by the court after his wife had him jailed for battery told the judge how sorry he was and suggested he needed psychiatric help. His history reveals acting-out behaviors as an adolescent and several adult arrests. The nurse interviews him about his relationship with his wife. Which statement by the patient is most consistent with a diagnosis of antisocial personality disorder? a. "I've done some stupid things in my life, but I've learned a lesson." b. "I'm feeling terrible about the way my behavior has hurt my family." c. "I have a quick temper, but I can usually keep it under control." d. "I hit her because she nags at me. She deserves it when I beat her up."

D The antisocial patient often impulsively acts out feelings of anger and usually feels no guilt or remorse. This patient rarely seems to change the behavioral patterns or otherwise learn from experience, commonly has problems with anger management and impulse control, and rarely feels true remorse.

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Ineffective airway clearance b. Ineffective coping c. Ineffective denial d. Risk for injury

D The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety is the nurse's priority. The scenario does not provide data to support the other diagnoses.

A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

Select the best comment for a nurse to begin an interview with an elderly patient. a. "I am a nurse. Are you familiar with what nurses do?" b. "Hello. I am going to ask you some questions to get to know you better." c. "You look comfortable and ready to participate in an admission interview. Shall we get started?" d. "Hello. My name is _______, and I am a nurse. How you would like to be addressed by staff?"

D The correct opening identifies the nurse's role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should always address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.

Every person who thinks about suicide should be considered to be: a. intending to kill himself. b. demonstrating impaired cognition. c. experiencing a mental illness. d. experiencing pain and hopelessness.

D The experience of intense emotional (and sometimes physical) pain and hopelessness are features which are very characteristic of people contemplating suicide. The other options reflect myths about suicide. Not all who consider or attempt suicide are intent on dying, and one does not have to have impaired thinking or a mental illness to consider suicide.

The history shows that a newly admitted patient has impulsivity. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. postponing gratification to an appropriate time. d. little time elapsed between thought and action.

D The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

An alcohol-dependent individual says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

D The individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

An adolescent whose peer committed suicide attempts suicide himself and is admitted to an inpatient mental health unit and assessed as being at high risk for self-harm. Which of the following nursing actions would be most appropriate to assure his safety during his first few days in the hospital? a. Place him on every-15-minute checks while awake. b. Search the patient and his belongings for dangerous material. c. Have him sign a no-suicide contract on arrival to the unit. d. Place him on direct one-to-one observation 24 hours a day.

D The most effective way to ensure safety for a person at high risk of self-harm is to observe that person directly at all times. Even when belongings are searched and all dangerous times are kept from the patient, it is still possible to acquire everyday items that can be used as a means for killing oneself, such as blankets, sheets, and the cords from electrical equipment. Checks made every 15 minutes still allow a window of opportunity (the 15 minutes between the checks) that is more than sufficient to permit the completion of suicide, particularly by hanging, the method most often resulting in suicide in inpatient settings. Limiting checks to when the patient is believed to be awake further reduces their effectiveness. The patient need only feign sleep or awaken in the middle of the night to have an opportunity for self-harm without being observed. Research has shown that no-suicide contracts are of limited value; while they may motivate some persons to seek help from staff before acting on suicide ideation, they cannot be counted on to reduce risk.

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are most important and which are less important."

D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

The nurse working the telephone suicide crisis line receives a call from a man who tells her he lives alone in a home several miles from his nearest neighbors. He has been considering suicide for 2 months. He has had several drinks and has loaded his shotgun, with which he plans to shoot himself in the chest. How should the nurse assess the lethality of this plan? a. No risk b. A low level of lethality c. A moderate level of lethality d. A high level of lethality

D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

A depressed patient is being seen in the clinic and started a selective serotonin reuptake inhibitor (SSRI) last week. She tells the nurse that she has some pills that she previously took for depression and that they are called MAOIs. She tells the nurse she thinks she should start taking them right now instead of her current medication, which isn't seeming to help her. The most important information the nurse should convey is: a. the need to have her blood pressure carefully monitored on MAOIs. b. that the SSRI antidepressant will be more effective as the weeks go by. c. the dietary restrictions required to take MAOIs antidepressants. d. the risk of a serious reaction if she begins the MAOIs on her own.

D The patient is at risk for a hypertensive crisis if she takes MAOIs after SSRIs without an appropriate washout period. The duration of the washout period is determined by the half-life of the SSRI. The other options are also part of patient education regarding MAOIs but are of lesser importance because they do not involve as immediate a safety risk as overlapping the SSRIs and MAOIs would present.

An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a(n): a. schizophrenic episode b. cocaine overdose c. phencyclidine (PCP) intoxication d. D-lysergic acid diethylamide (LSD) ingestionD

D The patient who has ingested LSD often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

An adult in the emergency department states, "Everything I see waves. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a. a schizophrenic episode. b. opium intoxication. c. cocaine overdose. d. LSD ingestion.

D The patient who is high on lysergic acid diethylamide (LSD) often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

A patient's spouse filed charges of battery. The patient says, "I'm sorry for what I did. I need psychiatric help." The patient has a long history of acting-out behaviors and several arrests. Which statement by the patient suggests an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I'm tired of being nagged. My spouse deserves the beating."

D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Ineffective airway clearance b. Ineffective coping c. Ineffective denial d. Risk for injury

D The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The scenario does not provide data to support the other diagnoses.

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "I'm burning up. I need help." The patient allows a temperature to be taken (it is 104° F), then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

A patient with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

D Therapeutic communication techniques can assist family members to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two of the incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

For which behavior would limit setting be most essential? The patient: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

D This option is an example of a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may be occasionally used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."

D This response gives the patient reinforcement and validation for making a positive response rather than acting out the 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 strategies.

An alcohol dependent patient says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the patient conceptualize the drinking more objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

D This response will help the patient see alcohol as a cause of the problems, not a solution. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." The best response for the nurse to make would be: a. "I wonder what this sudden change is all about. Care to elaborate?" b. "I am glad you are feeling better. The team will consider what you have said." c. "You should not try to direct your plan for care. Leave that to the team." d. "Because we are concerned about your safety, we will continue with our plan."

D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by staff. Asking the patient to elaborate could yield further evaluation data but would not reliably address suicide risk. Taking the patient's comment at face value neglects the fact that people can seek to conceal their plans in order to increase their chances of success. Asking the patient to "leave that to the team" conveys a parental attitude that would discourage the patient from participating in his treatment.

A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response? a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."D

D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get the bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry, I will have someone stay here and brush off the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you."

D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, "You must bathe daily." d. firmly and neutrally assist the patient with showering.

D When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

A 26-year-old woman who gave birth to a normal newborn 1 month ago reports she cannot cope with being a mom. She is unable to sleep, eats little, and says she feels like a failure because she can't take care of her baby. She has been thinking her baby is "the devil's work" and the cause of her problems. She sits and stares into space, her face a worried, perplexed mask. What would be the priority nursing diagnosis for this patient? a. Risk for impaired attachment b. Disturbed thought processes c. Situational low self-esteem d. Risk for other-directed violence

D When the mother with depression of postpartum onset has ruminations or delusional thoughts about the infant, the risk for harming the infant is increased; thus it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. I can't take care of my baby. This baby is the root of my problems." The priority nursing diagnosis is: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence

D When the mother with depression of postpartum onset has ruminations or delusional thoughts about the infant, the risk for harming the infant is increased; thus it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.