Psychiatric

The nurse evaluates a client with schizoaffective disorder. Which outcome best describes a favorable response to medication therapy? 1. High level of psychomotor activity and no longer hears voices. 2. Blunted facial expression and walks slowly, lacking an arm swing. 3. Performs appropriate self-grooming when prompted, and speech is coherent. 4. Walks with an arched back, and delusions of persecution are no longer expressed.

1) INCORRECT - A high level of psychomotor activity and no longer hearing voices describes akathisia and restlessness. These are extrapyramidal side effects of antipsychotics used to treat schizoaffective disorder. 2) INCORRECT - Blunted facial expression and walking without an arm swing are signs of drug-induced Parkinsonism, which is another form of extrapyramidal side effect. This is an unfavorable response. 3) CORRECT - Cooperative behavior and improved thought processes as evidenced by coherent speech are the expected therapeutic responses to antipsychotics. There is no evidence of extrapyramidal side effects. 4) INCORRECT - Walking with an arched back is a dystonic reaction, which is a form of extrapyramidal side effect, and is an unfavorable response to the medication.

A young adult is informed of the diagnosis of breast cancer by the health care provider. Which statement by the nurse is best? 1. "Do you have any questions about your diagnosis?" 2. "Tell me how you are feeling about what you have been told." 3. "I am sure you want to be alone for a few minutes." 4. "I will contact your minister."

1) INCORRECT - This is a closed-ended (yes/no) question and is not the most therapeutic. 2) CORRECT— This is an open-ended statement that allows the client to respond emotionally to the diagnosis. 3) INCORRECT - This is not therapeutic. The nurse should stay with the client. 4) INCORRECT - The nurse should first support the client. Later, the nurse can assess if the client would like a spiritual advisor to be contacted.

The elderly client diagnosed with chronic schizophrenia is cared for in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation includes which finding? 1. Assessment of ADL (self-care) ability. 2. Mini-Mental Status Examination (MMSE). 3. Abnormal Involuntary Movement Scale (AIMS). 4. Modified Overt Aggression Scale (MOAS).

1) assessment of client's abilities to complete the activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill but not related to tardive dyskinesia 2) measures cognitive function 3) CORRECT — most widely accepted examination to test for the presence of tardive dyskinesia 4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population

Which is most important for the rehabilitation nurse to assess during a new client's admission? 1. The client's expectations of family members. 2. The client's understanding of available supportive services. 3. The client's personal goals for rehabilitation. 4. The client's past experiences in the hospital.

1) important to assess but is not as crucial for future success as the client's goals 2) important to assess but is not as crucial for future success as the client's goals 3) CORRECT — it is important for the nurse to understand what the client expects from the rehabilitation program for future success 4) important to assess but is not as crucial for future success as the client's goals

Phobias are involved with which behaviors?

Projection & displacement

Symptoms of a panic attack:

-Increased BP -Increased HR & palpitations occur -Decreased perceptual field - the visual field narrows; part of the fight or flight reaction. -Diaphoresis - neurological changes cause diaphoresis. -Clients fear they are going crazy; part of the neurological changes.

The nurse plans care for the 20-year-old client. Which psychosocial stage does the nurse identify as the priority to consider? *** 1. Identity versus identity diffusion. 2. Intimacy versus isolation. 3. Integrity versus despair and disgust. 4. Industry versus inferiority.

1) appropriate for adolescents 2) CORRECT — this is the stage for 19- to 35-year-olds 3) for 65 years and older 4) for 6 to 12 years of age

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? ** Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.

1) related to schizophrenia. 2) CORRECT - delusions of grandeur are common during mania. 3) related to personality disorders. 4) CORRECT - due to excessive activity. 5) CORRECT - clients are constantly in motion. 6) related to depression.

AVOID asking what kind of questions?

"Why" questions

The nursing staff plans to use behavior modification techniques for the elderly client who constantly screams. Which nursing assessment is necessary to establish a successful program? 1. Monitor the client's ability to complete activities of daily living (ADL). 2. Assess the client's levels of pain and correlate it with the response to analgesia. 3. Observe the client's behavior at regular intervals to obtain baseline information related to the screaming. 4. Ask the client why screaming is occuring and document it on the nursing assessment record.

(1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program (2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program (3) correct—to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors (4) client may be unable to state screaming is occuring; asking "why" questions is nontherapeutic

The nurse cares for the client reporting moderate pain. Which nursing action is MOST important to provide the client with effective pain relief? 1. Teach the client about the pain. 2. Establish a trusting relationship with the client. 3. Determine how various relaxation techniques affect the pain. 4. Provide alternative measures to relieve pain.

(1) not most important (2) correct—necessary to work with client to identify interventions to relieve pain (3) part of the evaluation phase (4) only a portion of interventions used to relieve pain

An adult client is admitted to an acute locked psychiatric unit one month prior to an election. The client requests the opportunity to vote in the upcoming election. Which response by the nurse is best? 1. "You are not eligible to vote because you are a psychiatric client." 2. "I'll make the appropriate arrangements for you to vote." 3. "You may vote only if you are discharged by Election Day." 4. "I'll contact the Election Board to see if you are registered to vote."

(1) psychiatric patients do not forfeit their constitutional rights (2) correct—client can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility

The nurse plans care for the client hospitalized with bipolar disorder. While the client is in the manic phase, the nursing plan should include which intervention? Select all that apply. 1. Explain procedures in depth. 2. Distract the client with light physical activities 3. Isolate the client until manic phase is resolved 4. Concisely remind the client about the rules. 5. Provide prn medication for all inappropriate behaviors.

(1) will not be effective in changing behaviors, requires an attentive listener (2) correct—client experiences hyperactivity, poor concentration, and distractibility ; redirect into activity that promotes nourishment; are light activity (3) isolation not required, would increase anxiety and hostility (4) correct—clear concise information is appropriate (5) prn medication is a last result and used when physical harm is anticipated.

The nurse cares for the client with a long history of alcohol and drug dependence. It is most important for the nurse to include which action as part of discharge planning? 1. Refer to a social service agency for assistance with housing. 2. Refer to an aftercare center in the community. 3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor. 4. Ask the client to obtain a prescription for an antidepressant medication.

- Do not REFER action - What can the nurse do? 3) CORRECT — self-help groups have greatest success rate as a sustained support system in the community

Stages of grief:

1 - denial 2 - anger 3 - bargaining 4 - depression 5 - acceptance

The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom? 1. Delusions of persecution. 2. Command hallucinations. 3. Delusions of reference. 4. Persecution hallucinations.

1) CORRECT — client has delusions of persecution; delusion is a strongly held belief that is not validated by reality; the idea that a family member is trying to steal property is a belief not validated by reality 2) hallucinations are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone 3) delusions of reference are a false belief that public events or people are directly related to the individual 4) are not hallucinations

The client is diagnosed with an adjustment disorder with depressed mood. The client has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1. During the morning hours. 2. During the middle of the day. 3. During the afternoon hours. 4. During the evening hours.

1) CORRECT — client with reactive depression has the highest level of physical and psychic energy in the morning; as the day progresses, energy level declines

The nurse plans care for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1. Cause the client to defend the idea. 2. Help the client clarify thoughts. 3. Facilitate better communication. 4. Lead to a breakdown of the defense.

1) CORRECT — contraindicated; encourages client to engage in further distortion of reality 2) needs reality testing from nurse, not questioning 3) questioning is nontherapeutic; may cause client to avoid nurse physically 4) needs defense; questioning will further distort reality or elaborate on delusion

The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate? 1. Prepare a schedule of activities and monitor the client's participation in the activities. 2. Encourage the client to choose the client's own activities. 3. Allow the client time to get acclimated to the milieu before scheduling activities. 4. Allow the client to rest quietly to restore energy level.

1) CORRECT— The client displays symptoms of depression. For the client with depression, a regular daily routine of scheduled activities provides structure and decreases the amount of problem solving required. Participating in activities will increase self-esteem and assist the client to engage with others. 2) INCORRECT - The client is having difficulty making decisions. Choosing or planning the client's own activities will increase social isolation, increase impairment, and decrease self-esteem. 3) INCORRECT - This will increase social isolation. 4) INCORRECT - The client is having difficulty making decisions. Allowing the client to rest quietly will increase social isolation, increase impairment, and decrease self-esteem.

When assessing a client admitted to rule out a myocardial infarction, the nurse determines a history of alcoholism. Which question is a priority for the nurse to ask the client? 1. "What over-the-counter medications do you take? " 2. "How much alcohol do you consume each day? " 3. "When did you have your last drink? " 4. "Have you ever had symptoms of withdrawal? "

1) INCORRECT - Although asking about current medications is important, it is more important to determine when the client last had a drink. 2) INCORRECT - The amount of alcohol a client consumes will impact the severity of the withdrawal symptoms. However, it is more important for the nurse to anticipate when withdrawal might occur. 3) CORRECT— The symptoms of withdrawal occur from 48 to 72 hours after the last drink. This information helps the health care team determine needed medications and ensure client safety. 4) INCORRECT - Asking about previous withdrawal episodes is appropriate, but the priority is determining when withdrawal might occur.

The nurse collaborates with a nursing student to develop a plan of care for a client with dementia who was admitted with dehydration. To which nursing concern do they assign priority? 1. Chronic confusion. 2. Hypovolemia. 3. Bathing self-care deficit. 4. Risk for injury.

1) INCORRECT - The client diagnosed with dementia has a nursing concern of chronic confusion. The client's physiological needs take priority over safety and security needs, so hypovolemia takes priority over chronic confusion. 2) CORRECT— The client's physiological needs take priority. Since the client was admitted with dehydration and this is a direct threat to cardiac output and renal function, hypovolemia takes priority over the other nursing concerns. 3) INCORRECT - The client's physiological need identified by hypovolemia takes priority over the nursing concern of a bathing self-care deficit. 4) INCORRECT - The client diagnosed with dementia has a nursing concern of risk for injury; specifically, injury related to falls. However, the client's actual physiological needs take priority over potential, at risk, safety, and security needs, so the nursing concern of hypovolemia takes priority over risk for injury.

The nurse provides care for a client diagnosed with paranoid schizophrenia. The client's spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate? Assign the client to straighten up the day room. Establish a trusting nurse-client relationship. Encourage the client to sleep and offer a sleep aid. Introduce the client to other clients on the unit.

1) INCORRECT - The client diagnosed with paranoid schizophrenia views the world as hostile and threatening; therefore, the nurse's priority is to promote trust. Once the client is stable, this is an appropriate action to increase the sense of responsibility. 2) CORRECT — The client diagnosed with paranoid schizophrenia views the world as hostile and threatening, so the nurse's priority is promoting trust. Trust is promoted by establishing the nurse-client relationship. 3) INCORRECT - The client diagnosed with schizophrenia may experience hallucinations or delusions that impede trust and prevent sleep. While encouraging sleep is appropriate, this is not the immediate priority. 4) INCORRECT - Introducing the client to others on the unit before the client is more stable will not help the client. The priority is for the nurse to promote trust.

The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take first? Ride the elevator with the client. Encourage the client to get into the elevator. Allow the client to avoid the elevator. Encourage the client to discuss the fear.

1) INCORRECT - The spouse should acknowledge the client's concerns. While being present is important, the spouse should not expect the client to be able to ride the elevator immediately. 2) INCORRECT - The spouse should not attempt to remove the defense mechanism initially. 3) CORRECT— By allowing the client to avoid the elevator, the spouse will not increase the client's apprehension and anger. This maintains a better relationship. 4) INCORRECT - While appropriate, it is more important to allow the client to avoid the elevator. Phobia is not rational and responds best to systematic desensitization.

A client in the psychiatric unit continually states to the nurse, "My stomach is missing." Which response by the nurse is appropriate? 1. "Well then, you should not have any trouble losing weight." 2. "Where did your stomach go?" 3. "It sounds like you feel very empty and alone." 4. "I am here to help you, okay?"

1) INCORRECT - This is a nontherapeutic response that does not address the client's emotional state or offer reorientation to reality. 2) INCORRECT - The nurse should not explore a delusion and should not argue with the client having a delusion. The client will try to convince the nurse about the truth of the delusion. The nurse should instead respond to the client's emotional state. 3) CORRECT— Delusions often reflect the client's underlying emotion. The nurse should first respond to the client's emotional state, as in this response, and then reorient the client. 4) INCORRECT - This places the focus on the nurse and does not address the client's statement.

A facility's administration decides the psychiatric unit will move to a former medical-surgical unit in 2 months. The psychiatric nurse manager goes to the new unit to assess its structure. Which assessment finding most concerns the nurse manager? 1. The lights and floor coverings in the hallways. 2. The location of the nursing station in relationship to the client rooms. 3. The fixtures in the bathrooms in the clients' rooms. 4. The availability of a large central room for group meetings and socialization.

1) INCORRECT— If the lighting is breakable glass it can be addressed by replacement or covers prior to the unit move. Floors are vinyl or tile in facilities and not an issue. 2) INCORRECT—This could be of concern, but not the most concern. The staff can adapt to whatever configuration is available. 3) CORRECT — A client's bathroom can pose the most risk to client safety. Fixtures such as towel bars, shower bars, and safety rails should be made of materials that break away from the weight of a client attempting self-harm by hanging or jumping. Shower nozzles should be breakaway or recessed, and toilets should be low flush pressure. The lighting must be unbreakable. 4) INCORRECT— A dayroom is very important for a psychiatric unit so that community meetings as well as informal socialization and visitation can occur. However, client safety takes priority over all other concerns.

The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation most likely indicates bulimia? 1. Edema of the lower extremities. 2. The presence of lanugo. 3. Ulcerated oral mucous membranes. 4. Dry, yellowish colored skin.

1) common with anorexia 2) seen with anorexia 3) CORRECT — due to frequent vomiting 4) bulimics are normal in appearance

The nurse cares for the client diagnosed with bipolar disorder. The client will not stop swinging a mop to threaten other clients and staff. Which information is most important for the nurse to consider before administering a PRN IM dose of lorazepam? 1. The client is harmful to self. 2. The client is psychotic. 3. A less restrictive intervention failed. 4. The client is harmful to others.

1) important to know but not MOST important 2) should be considered but less restrictive interventions are considered first 3) CORRECT - use the least restrictive interventions in ascending order 4) a factor to consider, but consider less restrictive interventions first

Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."

1) indicates reaction formation 2) CORRECT — client has converted the anxiety over school performance into a physical symptom that interferes with the ability to perform 3) indicates denial 4) indicates projection

The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the initial priority nursing action? 1. Provide adequate hygiene and nutrition. 2. Decrease environmental stimuli. 3. Slowly involve the client in unit activities. 4. Administer and monitor sedative and mood-stabilizing medications.

1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority 2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression 3) this action is inappropriate at this time 4) CORRECT — is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents

The client begins outpatient therapy sessions for management of a phobic disorder. The nurse identifies which intervention is most effective to reduce the client's symptoms? 1. Antianxiety medication. 2. Group psychotherapy. 3. Systematic desensitization. 4. Biofeedback.

1) may be used for social phobia or social anxiety disorder 2) may benefit from cognitive-behavioral therapy 3) CORRECT — phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavior modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response 4) one learns to control the autonomic nervous system; is usually more useful for reducing stress associated with physiologically based disorders

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis? 1. Social interaction impairment. 2. Potential activity intolerance. 3. Powerlessness. 4. Difficulty with coping.

1) not warranted with the data indicated 2) not warranted with the data indicated 3) not warranted with the data indicated 4) CORRECT — client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is inability to cope

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.

1) related to schizophrenia. 2) CORRECT - delusions of grandeur are common during mania. 3) related to personality disorders. 4) CORRECT - due to excessive activity. 5) CORRECT - clients are constantly in motion. 6) related to depression.

The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the emergency department. The nurse knows the most common reaction of the significant other to a rape victim is reflected in which behavior? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying the need for help. 4. Emotionally distressed and needing assistance.

1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so 2) rarely feel disconnected 3) usually family members will need and respond well to psychological intervention 4) CORRECT — sexual assault by rape is a crisis situation for victim and family members and friends

Eriksons stages of development: **

Birth - 1 year {0 - 18 months} = trust v mistrust 1 - 3 years = Autonomy v shame & doubt 3 - 6 years = initiative v guilt 6 - 11 = Industry v inferiority (school age) 11 - 19 = Identity v role confusion 19 - 39 = intimacy v isolation 40 - 65 = generativity v stagnation 65+ = Integrity v despair

The nurse cares for the client admitted 4 days ago for treatment of alcohol dependence. The client has slurred speech, ataxia, and uncoordinated movements, and reports a headache. Which action does the nurse take first? 1. Observe the client for 8 hours to collect additional data. 2. Perform a complete physical assessment. 3. Collect a urine specimen for a drug screen. 4. Encourage the client to talk about whatever is causing distress.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? Yes. 1) will not provide the data that a physical assessment would; may be a medical emergency requiring an immediate intervention 2) CORRECT — best way to identify possible physical complications of alcohol dependence is through a complete physical assessment 3) should be done after the physical assessment is completed 4) inaccurate because the symptoms are most likely caused by physical and not psychological stressors

A college student reports a history of a motor vehicle accident six months ago. The client was minimally injured but a friend was killed. The client comes to Student Health Services reporting inability to study or sleep. The client also reports thinking they are "going crazy." Which action by the nurse is MOST important? 1. Perform a complete physical and social history. 2. Obtain a complete drug and alcohol history, including reports from a drug screen. 3. Review the significant events of the last year. 4. Explore the client's coping methods over the crash and the friend's death.

Strategy: Determine the outcome of each answer choice. (1) not most important initially (2) not most important initially (3) not most important initially (4) correct—situational crisis; priority is to determine how client coped with crisis in the past and build on client's coping strategies

A client with anorexia nervosa may have what problem?

clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do

Anorexia nervosa: Assessment:

is an eating disorder characterized by an abnormally low body weight, intense fear of gaining weight and a distorted perception of body weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with activities in their lives. To prevent weight gain or to continue losing weight, people with anorexia usually severely restrict the amount of food they eat. They may control calorie intake by vomiting after eating or by misusing laxatives, diet aids, diuretics or enemas. They may also try to lose weight by EXERCISING EXCESSIVELY. Some people with anorexia binge and purge, similar to individuals who have bulimia nervosa. However, people with anorexia generally struggle with an abnormally LOW body weight, while individuals with bulimia typically are normal to above normal weight. No matter how weight loss is achieved, the person with anorexia has an intense fear of gaining weight. - edema of lower extremities - presence of lanugo - thin appearance

Bulimia nervosa: Two categories: Assessment:

potentially life-threatening eating disorder. People with bulimia may secretly binge — eating large amounts of food — and then purge, trying to get rid of the extra calories in an unhealthy way. For example, someone with bulimia may force vomiting or engage in excessive exercise. Sometimes people purge after eating only a small snack or a normal-size meal. - Purging bulimia: You regularly self-induce vomiting or misuse laxatives, diuretics or enemas after bingeing. - Nonpurging bulimia: You use other methods to rid yourself of calories and prevent weight gain, such as fasting, strict dieting or excessive exercise. - ulcerated mucous membranes due to vomiting - usually normal or above normal body weight

Abusive language in a psych pt can be?

symptomatic behavior of the clients illness