Q Mental Health - Substance Abuse Quiz EXAM 2 Combine, Q Substance-Related Disorders Combine, Q Townsend: Unit 5 Combine, **QChapter 14: Substance Use and Addictive Disorders - has ques from test 5 - Combine, **Psych Unit 6 Quizes for Test #2** P, Q...

Which nursing statement best describes the current nature of mental health care in the community? A. "All homeless people have a history of institutionalization and are frequently admitted to acute care settings." B. "The deinstitutionalization movement in the United States was successful in transitioning clients into the community." C. "Today, the majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization."

C. "Today, the majority of clients admitted to psychiatric hospitals are in a crisis stage, and the treatment goal is stabilization."

7. A newly admitted homeless client diagnosed with schizophrenia states, "I have been living in a cardboard box for two weeks. Why did the government let me down?" Which is an appropriate nursing response? A. "Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless. "B. "Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia. C. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success.

C. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success.

Which intervention should the nurse consider as primary prevention for an individual who is on the verge of being homeless because of a job layoff? A. Referral to primary care provider to improve general health status B. Encouraging client to recognize reasons for job layoff C. Job training to increase employment options D. Encouraging the use of prn medications to control symptoms

C. Job training to increase employment options

1. A nursing instructor is teaching about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act? A. Many perspective clients did not meet criteria for mental illness diagnostic-related groups. B. Zoning laws discouraged the development of community mental health centers. C. States could not match federal funds to establish community mental health centers. D. There was not a sufficient employment pool to staff community mental health centers.

C. States could not match federal funds to establish community mental health centers.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? Select one: a. Antagonist therapy b. Deterrent therapy c. Codependency therapy d. Substitution therapy

D CNS depressants are additive with one another. When a CNS depressant is used in combination with alcohol, the depressive effects are compounded. There may be cross-dependence in which one drug can prevent withdrawal symptoms of another drug.

Which client statement indicates a knowledge deficit related to substance abuse? Select one: a. "Although it's legal, alcohol is one of the most widely abused drugs in our society." b. "Tolerance to heroin develops quickly." c. "Flashbacks from LSD use may reoccur spontaneously." d. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

Which client statement demonstrates positive progress toward recovery from substance abuse? Select one: a. "I have completed detox and therefore am in control of my drug use." b. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." c. "As a church deacon, my focus will now be on spiritual renewal." d. "Taking those pills got out of control. It cost me my job, marriage, and children."

D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery from substance abuse. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? Select one: a. To assess for emotional strength. b. To assess for Wernicke-Korsakoff syndrome. c. To assess for tachycardia. d. To assess for fine tremors.

D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? Select one: a. Haloperidol (Haldol) and fluoxetine (Prozac) b. Carbamazepine (Tegretol) and donepezil (Aricept) c. Disulfiram (Antabuse) and lorazepan (Ativan) d. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant.

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? Select one: a. The client will identify one person to turn to for support. b. The client will give up all old drinking buddies. c. The client will be able to verbalize the effects of alcohol on the body. d. The client will correlate life problems with alcohol use.

D The nurse should expect that the client would initially correlate life problems with alcohol abuse. Acceptance of the problem is the first part of the recovery process.

5. When intervening with a married couple experiencing relationship discord, which nursing action reflects an intervention at the secondary level of prevention? A. Teaching assertiveness skills in order to meet assessed needs B. Supplying the couple with guidelines related to marital seminar leadership C. Teaching the couple about various methods of birth control D. Counseling the couple related to open and honest communication skills

D. Counseling the couple related to open and honest communication skills

A client diagnosed with schizophrenia was released from a state mental hospital aftr 20yrs of institutionalization. Which characteristic that is likely to be exhibited by this client? A. The client is likely to be compliant with treatment because of institutional dependency. B. The client is likely to find a variety of community support services to aid in the transition. C. The client is likely to adjust to the community environment if given sufficient support. D. The client is likely to be admitted at some time to an acute care unit for psychiatric treatment.

D. The client is likely to be admitted at some time to an acute care unit for psychiatric treatment.

1. ___________________________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

Mania

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) 1. Binge eating with a diagnosis of obesity 2. Bingeing and purging with a diagnosis of bulimia nervosa 3. Weight loss with a diagnosis of anorexia nervosa 4. Amenorrhea with a diagnosis of anorexia nervosa 5. Emaciation with a diagnosis of bulimia nervosa

1, 2

Which of the following rationales by a nurse explain to parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.)\ 1.Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2.Children are naturally active, energetic, and spontaneous. 3.Neurotransmitter levels vary considerably in accordance with age. 4.The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 5.Genetic predisposition is not a reliable diagnostic determinant.

1, 2

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1.Avoid excessive use of beverages containing caffeine. 2.Maintain a consistent sodium intake. 3.Consume at least 2,500 to 3,000 mL of fluid per day. 4.Restrict sodium content. 5.Restrict fluids to 1,500 mL per day.

1, 2, 3

Which of the following would contribute to a client's excessive weight gain? (Select all that apply.) 1. A hypothalamus lesion 2. Hyperthyroidism 3. Diabetes mellitus 4. Cushing's disease 5. Low levels of serotonin

1, 3, 4

A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (Select all that apply.) 1. "In this disorder, binge eating occurs exclusively during the course of bulimia nervosa." 2. "In this disorder, binge eating occurs, on average, at least once a week for three months." 3. "In this disorder, binge eating occurs, on average, at least two days a week for six months." 4. "In this disorder, distress regarding binge eating is present." 5. "In this disorder, distress regarding binge eating is absent."

1, 3, 5

A client, who is taking transdermal selegiline (Emsam) for depressive symptoms, states, "My physician told me there was no need to worry about dietary restrictions." Which would be the most appropriate nursing response? 1. "Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended." 2. "You must have misunderstood. An MAOI like Emsam always has dietary restrictions." 3. "Only oral MAOIs require dietary restrictions." 4. "All transdermal MAOIs do not require dietary modifications."

1. "Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended."

A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders? 1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. 2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. 3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. 4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not

1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.

Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client? 1. On his or her side, to prevent aspiration 2. In high Fowler's position, to prevent increased intracranial pressure 3. In Trendelenburg's position, to promote blood flow to vital organs 4. In prone position, to prevent airway blockage

1. On his or her side, to prevent aspiration

A morbidly obese client is prescribed an anorexiant medication. The nurse should expect to teach the client about which medication? 1. Phentermine (Mirapront) 2. Dexfenfluramine (Redux) 3. Sibutramine (Meridia) 4. Pemoline (Cylert)

1. Phentermine (Mirapront)

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1. Risk for suicide R/T hopelessness

A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide? 1. The emesis produced during purging is acidic and corrodes the tooth enamel. 2. Purging causes the depletion of dietary calcium. 3. Food is rapidly ingested without proper mastication. 4. Poor dental and oral hygiene leads to dental caries

1. The emesis produced during purging is acidic and corrodes the tooth enamel

A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis? 1. Thyroid-stimulating hormone (TSH) level of 25 U/mL 2. Potassium (K+) level of 4.2 mEq/L 3. Sodium (Na+) level of 140 mEq/L 4. Calcium (Ca2+) level of 9.5 mg/dL

1. Thyroid-stimulating hormone (TSH) level of 25 U/mL

A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lbs. by the end of the week?" 1.Provide client with high-calorie finger foods throughout the day. 2.Accompany client to cafeteria to encourage adequate dietary consumption. 3.Initiate total parenteral nutrition to meet dietary needs. 4.Teach the importance of a varied diet to meet nutritional needs.

1.Provide client with high-calorie finger foods throughout the day.

16. Order the goals of the levels of prevention as they progress through the public health model set forth by Gerald Caplan. 1. ________ Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness 2. ________ Services aimed at reducing the residual defects that are associated with severe and persistent mental illness 3. ________ Services aimed at reducing the incidence of mental disorders within the population

2, 3, 1

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response? 1. "This combination of drugs can lead to delirium tremens." 2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." 3. "That's a good idea. There have been good results with the combination of these two drugs." 4. "The only disadvantage would be the exorbitant cost of the MAOI."

2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis."

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response? 1. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." 2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." 3. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." 4. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."

After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem? 1. "Are you consuming foods high in tyramine?" 2. "How many packs of cigarettes do you smoke daily?" 3. "Do you drink any alcohol?" 4. "Are you taking St. John's wort?"

2. "How many packs of cigarettes do you smoke daily?"

A nurse is working with a client who has just been prescribed buproprion (Wellbutrin). Which statement by the client indicates that further education is necessary? 1. "I will begin using sunblock when outdoors." 2. "If I miss a dose, I will just take two pills the next day to catch up." 3. "I will only discontinue the medication under the guidance of my physician." 4. "I will use caution when driving and using dangerous machinery."

2. "If I miss a dose, I will just take two pills the next day to catch up."

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode? 1. The attention during the assessment is beneficial in decreasing social isolation. 2. Depression can generate somatic symptoms that can mask actual physical disorders. 3. Physical health complications are likely to arise from antidepressant therapy. 4. Depressed clients avoid addressing physical health and ignore medical problems.

2. Depression can generate somatic symptoms that can mask actual physical disorders.

A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client? 1. Zung Depression Scale 2. Hamilton Depression Rating Scale 3. Beck Depression Inventory 4. AIMS Depression Rating Scale

2. Hamilton Depression Rating Scale

The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms? 1. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions) 2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 3. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia) 4. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)

2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? 1. Altered communication R/T feelings of worthlessness AEB anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered thought processes R/T hopelessness AEB persecutory delusions 4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

2. Social isolation R/T poor self-esteem AEB secluding self in room

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2. Valproic acid (Depakote)

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-lb. weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1.Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2.Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3.Risk for suicide R/T powerlessness AEB insomnia and anorexia 4.Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2.Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1.Increase the dosage of fluoxetine. 2.Discontinue the fluoxetine and rethink the client's diagnosis. 3.Order benztropine (Cogentin) to address extrapyramidal symptoms. 4.Order olanzapine (Zyprexa) to address altered thoughts.

2.Discontinue the fluoxetine and rethink the client's diagnosis.

Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1.Medication adherence 2.Empowerment of the consumer 3.Total absence of symptoms 4.Improved psychosocial relationships

2.Empowerment of the consumer

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? The following are the outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

3, 1, 4, 2

A client who has been newly diagnosed with depression is beginning tricyclic antidepressant therapy. The nurse has just completed teaching with this client. Which statement by the client indicates the need for further education? 1. "I will continue to take this medication even if the symptoms have not subsided." 2. "I may experience drowsiness or dizziness while taking this medication." 3. "I do not need to quit smoking." 4. "I will stop drinking alcohol now that I am taking this medication."

3. "I do not need to quit smoking."

The nurse educator is lecturing a group of nursing students on depression in adolescents. Which statement indicates that teaching has been effective? 1. "Adolescents are not likely to suffer from depression." 2. "Depressed adolescents always seek immediate treatment." 3. "Many symptoms are attributed to normal adjustments of adolescents." 4. "Suicide is not common among depressed adolescents."

3. "Many symptoms are attributed to normal adjustments of adolescents."

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

3. "Weight gain is a common, but troubling, side effect."

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? 1. According to psychoanalytic theory, depression is a result of negative perceptions. 2. According to object-loss theory, depression is a result of overprotection. 3. According to learning theory, depression is a result of repeated failures. 4. According to cognitive theory, depression is a result of anger turned inward.

3. According to learning theory, depression is a result of repeated failures.

A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time? 1. Obtaining an order for locked seclusion until client is no longer suicidal 2. Conducting 15-minute checks to ensure safety 3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations 4. Encouraging client to express feelings related to suicide

3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? 1. The client gained two pounds in one week. 2. The client focused conversations on nutritious food. 3. The client demonstrated healthy coping mechanisms that decreased anxiety. 4. The client verbalized an understanding of the etiology of the disorder

3. The client demonstrated healthy coping mechanisms that decreased anxiety.

A client's altered body image is evidenced by claims of "feeling fat," even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? 1. The client will consume adequate calories to sustain normal weight. 2. The client will cease strenuous exercise programs. 3. The client will perceive personal ideal body weight and shape as normal. 4. The client will not express a preoccupation with food.

3. The client will perceive personal ideal body weight and shape as normal.

A nurse administers 100 percent oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? 1. To prevent increased intracranial pressure resulting from anoxia 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation 3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles 4. To prevent blocked airway, resulting from seizure activity

3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles

A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam? 1. To rule out bipolar disorder 2. To rule out schizophrenia 3. To rule out neurocognitive disorder 4. To rule out personality disorder

3. To rule out neurocognitive disorder

A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1.During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2.During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3.During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4.During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

3.During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.

A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1.Symptoms lasting for a minimum of two years 2.Numerous periods with manic symptoms 3.Possible comorbid diagnosis of a delusional disorder 4.Symptoms cause clinically significant impairment in important areas of functioning 5.Depressive symptoms that do not meet the criteria for major depressive episode

4, 5

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder? 1. "Skaters need to be thin to improve their daily performance." 2. "All the skaters on the team are following an approved 1200-calorie diet." 3. "The exercise of skating reduces my appetite but improves my energy level." 4. "I am angry at my mother. I can only get her approval when I win competitions."

4. "I am angry at my mother. I can only get her approval when I win competitions."

A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives? 1. "It's all my fault for trusting him." 2. "I don't play games. I never win." 3. "She never visits, because she thinks I don't care." 4. "I don't have a green thumb. Any old fool can grow a rose."

4. "I don't have a green thumb. Any old fool can grow a rose."

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, "My parents watch me like a hawk and never let me out of their sight." Which nursing diagnosis would take priority at this time? 1. Altered nutrition less than body requirements 2. Altered social interaction 3. Impaired verbal communication 4. Altered family processes

4. Altered family processes

A nurse is planning care for a 13-year-old client who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents? 1. Paroxetine (Paxil) 2. Sertraline (Zoloft) 3. Citalopram (Celexa) 4. Escitalopram (Lexapro)

4. Escitalopram (Lexapro) Fluoxetine (Prozac)

An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why? 1. Neuroleptic malignant syndrome; caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) 2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) 3. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI 4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis? 1. The client is disheveled and malodorous. 2. The client refuses to interact with others and isolates self in room. 3. The client is unable to feel any pleasure. 4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

4. The client has maxed-out charge cards and exhibits promiscuous behaviors.

When planning care for a depressed client, which correctly written outcome should be a nurse's first priority? 1. The client will promise not to physically harm self. 2. The client will discuss feelings with staff and family by day three. 3. The client will establish a trusting relationship with the nurse. 4. The client will remain safe during hospital stay.

4. The client will remain safe during hospital stay.

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

4."Agitated and pacing. Exhibiting grandiosity. Mood labile."

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1."Treatment is compromised when clients can't sleep." 2."Treatment is compromised when irritability interferes with social interactions." 3."Treatment is compromised when clients have no insight into their problems." 4."Treatment is compromised when clients choose not to take their medications."

4."Treatment is compromised when clients choose not to take their medications."

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1.Symptoms indicate consumption of foods high in tyramine. 2.Symptoms indicate lithium carbonate discontinuation syndrome. 3.Symptoms indicate the development of lithium carbonate tolerance. 4.Symptoms indicate lithium carbonate toxicity.

4.Symptoms indicate lithium carbonate toxicity.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to Alcoholics Anonymous (AA), would be most appropriate for a nurse to discuss with the client during discharge teaching? Select one: a. After discharge, the client will immediately attend 90 AA meetings in 90 days. b. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. c. After discharge, the client will incorporate family in AA attendance. d. After discharge, the client will seek appropriate deterrent medications through AA.

A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? Select one: a. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. b. Sedative-hypnotics are expensive and have numerous side effects. c. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. d. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological dependence.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? a. Risk for injury R/T central nervous system stimulation. b. Disturbed thought processes R/T tactile hallucinations. c. Ineffective coping R/T powerlessness over alcohol use. d. Ineffective denial R/T continued alcohol use despite negative consequences

A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? Select one: a. Psychological dependency b. Physical dependency c. Substance dependency d. Social dependency

A client is considered to be psychologically dependent on a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort.

A client has a history of drinking one pint of bourbon per day for the past 6 months. He is brought to an emergency department by family members who report that his last drink was 1 hour ago. It is now 12 a.m. When should a nurse expect this client to begin experiencing withdrawal symptoms? Select one: a. Between 3 a.m. and 11 a.m. b. Shortly after a 24-hour period. c. At the beginning of the third day. d. Withdrawal is individualized and cannot be predicted.

A The nurse should expect that the client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

A nursing instructor is teaching nursing students about cirrhosis of the liver. Which statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.) Select one or more: a. "A diet rich in protein will promote hepatic healing." b. "This condition results from a rise in serum ammonia leading to impaired mental functioning." c. "In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity." d. "Neomycin and lactulose are used in the treatment of this condition." e. "This condition is caused by the inability of the liver to convert ammonia to urea."

A , C The nursing instructor should understand that further teaching is needed if the nursing students state that a diet rich in protein will promote hepatic healing and that this condition causes an excessive amount of fluid to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion. The nursing instructor should understand that further teaching is needed if the nursing students state that a diet rich in protein will promote hepatic healing and that this condition causes an excessive amount of fluid to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

Which one of the following clients is most likely to develop acute respiratory distress syndrome? A 20-year-old with fractures of the tibia A 36-year-old who is HIV positive A 40-year-old with duodenal ulcers A 32-year-old with barbiturate overdose

A 32-year-old with barbiturate overdose

A home health nurse has several elderly clients in her case load. Which of the following clients is most likely to be a victim of elder abuse? A 76-year-old female with Alzheimer's dementia A 70-year-old male with diabetes mellitus A 64-year-old female with a hip replacement A 72-year-old male with Parkinson's disease

A 76-year-old female with Alzheimer's dementia

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the client's motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

15. Which of the following have been assessed as the most common types of mental illness identified among homeless individuals? (Select all that apply.)A. Schizophrenia B. Body dysmorphic disorder C. Antisocial personality disorder D. Neurocognitive disorder E. Conversion disorder

A, C, D

Which nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.) Select one or more: a. "I am easily manipulated and need to work on this prior to caring for these clients." b. "Because of my father's alcoholism, I need to examine my attitude toward these clients." c. "I need to review the side effects of the medications used in the withdrawal process." d. "I'll need to set boundaries to maintain a therapeutic relationship." e. "I need to take charge when dealing with clients diagnosed with substance disorders."

A,B,D The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients. The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients. The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients.

4. A client at the mental health clinic tells the case manager, "I can't think about living another day, but don't tell anyone about the way I feel. I know you are obligated to protect my confidentiality." Which case manager response is most appropriate? A. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care. "B. "Let's discuss steps that will resolve negative lifestyle choices that may have increased your suicidal risk. "C. "You seem to be preoccupied with self. You should concentrate on hope for the future. "D. "This information is secure with me because of client confidentiality."

A. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care.

17. ________________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

ANS: Mania Page: 419 Feedback: Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

10. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lbs. by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

ANS: 1 Page: 427-430 Feedback 1 The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lbs. by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals. 2 Accompanying the client to the cafeteria is not realistic. 3 Initiating total parenteral nutrition is not realistic. 4 Education is important, but is unrealistic to help the client gain weight by the end of the week.

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

ANS: 1 Page: 427-430 Feedback 1 The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt. 2 Anxiety: severe R/T hyperactivity does not address the client's risk for suicide. 3 Imbalanced nutrition: less than body requirements R/T refusal to eat does not address the client's risk for suicide. 4 Dysfunctional grieving R/T loss of employment does not address the client's risk for suicide.

ANS: 4 Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

ANS: 1 Rationale: The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcohol addiction. It accepts alcohol addiction as an illness and promotes total abstinence as the only cure.

A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? 1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. 2. Sedative-hypnotics are expensive and have numerous side effects. 3. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. 4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

ANS: 1 Rationale: The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. The effects of central nervous system depressants are additive with one another, capable of producing physiological and psychological addiction.

A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? 1. Psychological addiction 2. Physical addiction 3. Substance induced disorder 4. Social induced disorder

ANS: 1 Rationale: The nurse should use the term psychological addiction to best describe the client's situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a drug in order to produce pleasure or avoid discomfort.

A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.) 1. "A diet rich in protein will promote hepatic healing." 2. "This condition results from a rise in serum ammonia, leading to impaired mental functioning." 3. "In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity." 4. "Neomycin and lactulose are used in the treatment of this condition." 5. "This condition is caused by the inability of the liver to convert ammonia to urea."

ANS: 1 Rationale: The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing. The treatment of hepatic encephalopathy requires abstention from alcohol and temporary elimination of protein from the diet.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? 1. Risk for injury R/T central nervous system stimulation 2. Disturbed thought processes R/T tactile hallucinations 3. Ineffective coping R/T powerlessness over alcohol use 4. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: 1 Rationale: The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

A nurse is assessing a pathological gambler. What would differentiate this client's behaviors from the behaviors of a non-pathological gambler? 1. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. 2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men. 3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course. 4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief

ANS: 1 Rationale: There is a correlation between pathological gambling and abnormalities in the serotonergic, noradrenergic, and dopaminergic neurotransmitter systems. This is not the case with non-pathological gambling. For a pathological gambler, the preoccupation with and impulse to gamble intensifies when the individual is under stress. This is not the case with non-pathological gambling. Pathological gambling occurs more commonly among men not women and generally runs a chronic not acute course.

16. Which of the following rationales by a nurse explain to parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 5. Genetic predisposition is not a reliable diagnostic determinant.

ANS: 1, 2 Page: 424-425 Feedback 1. It is difficult to diagnose a child or adolescent with bipolar disorder, because bipolar symptoms mimic attention deficit hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitters levels do not vary according to age. 4. Bipolar disorder can be diagnosed for the age of 18. 5. Genetic predisposition can be a reliable diagnostic determinant.

14. Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Restrict sodium content. 5. Restrict fluids to 1,500 mL per day.

ANS: 1, 2, 3 Page: 434, 439-440 Feedback 1. The nurse should instruct the client taking lithium to avoid excessive use of caffeine. 2. The nurse should instruct the client taking lithium to maintain a consistent sodium intake. 3. The nurse should instruct the client taking lithium to consume at least 2,500 to 3,000 mL of fluid per day. 4. Fluid restriction can impact lithium levels. 5. Sodium restriction can impact lithium levels.

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with a substance-related disorder? (Select all that apply.) 1. "I am easily manipulated and need to work on this prior to caring for these clients." 2. "Because of my father's alcoholism, I need to examine my attitude toward these clients." 3. "I need to review the side effects of the medications used in the withdrawal process." 4. "I'll need to set boundaries to maintain a therapeutic relationship." 5. "I need to take charge when dealing with clients diagnosed with substance disorders."

ANS: 1, 2, 4 Rationale: The nurse should complete a cognitive process prior to caring for clients diagnosed with substance-abuse disorders. It is important for nurses to identify potential areas of need within their own cognitions that may affect their relationships with clients diagnosed with this problem.

A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.) 1. Stressful situations precipitate gambling behaviors. 2. Anxiety and restlessness can only be relieved by placing a bet. 3. Winning brings about feelings of sexual satisfaction. 4. Gambling is used as a coping strategy. 5. Losing at gambling meets the client's need for self-punishment.

ANS: 1, 2, 4, 5 Rationale: In gambling disorder, the preoccupation with and impulse to gamble intensifies when the individual is under stress. Many impulsive gamblers describe a physical sensation of restlessness and anticipation that can only be relieved by placing a bet. Winning brings feelings of special status, power, and omnipotence, not sexual satisfaction. The gambler increasingly depends on this activity to cope with disappointments, problems, and negative emotional states.

A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.) 1. The client has a long history of focusing thoughts and behaviors on other people. 2. The client, as a child, experienced overindulgent and overprotective parents. 3. The client is a people pleaser and does almost anything to gain approval. 4. The client exhibits helpless behaviors but actually feels very competent. 5. The client can achieve a sense of control only through fulfilling the needs of others.

ANS: 1, 3, 5 Rationale: The codependent person has a long history of focusing thoughts and behavior on other people and is able to achieve a sense of control only through fulfilling the needs of others. Codependant clients are "people pleasers" and will do almost anything to get the approval of others. They usually have experienced abuse or emotional neglect as a child. They outwardly appear very competent, but actually feel quite needy, helpless, or perhaps nothing at all.

A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.) 1. A hotline number will be available in order to call for peer assistance. 2. A verbal contract detailing the method of treatment will be initiated prior to the program. 3. Peer support is provided through regular contact with the impaired nurse. 4. Contact to provide peer support will last for one year. 5. One of the program goals is to intervene early in order to reduce hazards to clients.

ANS: 1, 3, 5 Rationale: The peer assistance programs strive to intervene early, to reduce hazards to clients, and increase prospects for the nurse's recovery. Most states provide either a hotline number that the impaired nurse may call or phone numbers of peer assistance committee members, which are made available for the same purpose. Typically, a written, not verbal, contract is drawn up, detailing the method of treatment, which may be obtained from various sources, such as employee assistance programs, Alcoholics Anonymous, Narcotics Anonymous, private counseling, or outpatient clinics. Peer support is provided through regular contact with the impaired nurse, usually for a period of two years, not one year.

2. A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-lb. weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

ANS: 2 Page: 419-422 Feedback 1 Knowledge deficit R/T bipolar disorder AEB concern about symptoms does not identify the client's sudden 12-lb. weight loss. 2 The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health. 3 Risk for suicide R/T powerlessness AEB insomnia and anorexia does not identify the client's sudden 12-lb. weight loss. 4 Altered sleep patterns R/T mania AEB insomnia for the past 3 nights does not identify the client's sudden 12-lb. weight loss.

12. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.

ANS: 2 Page: 424-425 Feedback 1 Increasing the dosage would not help this client. 2 A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis. It would be inappropriate to increase the dosage of fluoxetine. 3 The client is not having extrapyramidal symptoms. 4 The client is not having altered thoughts.

13. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

ANS: 2 Page: 433-434 Feedback 1 Medication adherence is not the basic premise of the recovery model for bipolar disorder. 2 The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. 3 Absence of symptoms is not the basic premise of the recovery model for bipolar disorder. 4 Improved psychosocial relationships is not the basic premise of the recovery model for bipolar disorder.

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

ANS: 2 Page: 435-438 Feedback 1 Sertraline (Zoloft) does not counteract the weight-increasing effects of lithium. 2 The nurse should anticipate that the physician may prescribe valproic acid in order to increase this client's medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss. 3 Trazodone (Desyrel) does not counteract the weight increasing effects of lithium. 4 Paroxetine (Paxil) does not counteract the weight increasing effects of lithium.

A nursing instructor is teaching about the impaired nurse and the consequences of this impairment. Which statement by a student indicates that further instruction is needed? 1. "The state board of nursing must be notified with factual documentation of impairment." 2. "All state boards of nursing have passed laws that, under any circumstances, do not allow impaired nurses to practice." 3. "Many state boards of nursing require an impaired nurse to successfully complete counseling treatment programs prior to a return to work." 4. "After a return to practice, a recovering nurse may be closely monitored for several years."

ANS: 2 Rationale: Several state boards of nursing have passed diversionary laws that allow impaired nurses to avoid disciplinary action by agreeing to seek treatment. This may require successful completion of inpatient, outpatient, group, or individual counseling treatment program(s); evidence of regular attendance at nurse support groups or 12-step program; random negative drug screens; and employment or volunteer activities during the suspension period. When a nurse is deemed safe to return to practice, he or she may be closely monitored for several years and required to undergo random drug screenings.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction? 1. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 2. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control. 3. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 4. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment.

ANS: 2 Rationale: The nurse should assess the client for substance addiction, because clients who are addicted to alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? 1. 50 mg/dL 2. 100 mg/dL 3. 250 mg/dL 4. 300 mg/dL

ANS: 2 Rationale: The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptom should be the nurse's first priority? 1. Hearing and visual impairment 2. Blood pressure of 180/100 mm Hg 3. Mood rating of 2/10 on numeric scale 4. Dehydration

ANS: 2 Rationale: The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal syndrome and should promptly report this finding to the physician. Complications associated with alcohol withdrawal syndrome may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol use.

A nursing supervisor is about to meet with a staff nurse suspected of diverting client medications. Which of the following assessment data would lead the supervisor to suspect that the staff nurse is impaired? (Select all that apply.) 1. The staff nurse is frequently absent from work. 2. The staff nurse experiences mood swings. 3. The staff nurse makes elaborate excuses for behavior. 4. The staff nurse frequently uses the restroom. 5. The staff nurse has a flushed face.

ANS: 2, 3, 4, 5 Rationale: A number of clues for recognizing substance impairment in nurses have been identified. They are not easy to detect and will vary according to the substance being used. There may be high absenteeism if the person's source is outside the work area, or the individual may rarely miss work if the substance source is at work. Some other possible signs are irritability, mood swings, tendency to isolate, elaborate excuses for behavior, unkempt appearance, impaired motor coordination, slurred speech, flushed face, inconsistent job performance, and frequent use of the restroom.

3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? The following are the outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. 1. 2, 1, 3, 4 2. 4, 1, 2, 3 3. 3, 1, 4, 2 4. 1, 4, 2, 3

ANS: 3 Page: 419-422 Feedback 1 The client's safety and physical health is the most important. 2 Safety is the priority. 3 The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's safety and physical health as most important 4 The nurse should always prioritize safety.

11. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

ANS: 3 Page: 425-426 Feedback 1 These symptoms are present in both hyper- and hypomania. 2 Decreased need for sleep can be present in hypomania. 3 Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic. 4 These symptoms can be present in hypomania.

7. A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

ANS: 3 Page: 427 Feedback 1 Weight loss is not typical with this drug. 2 Clients gain weight regardless of diet with Lithium therapy. 3 The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication. 4 Weight gain is a common side effect with this medication.

A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the client's physician to treat this disorder. The nurse would give the client information on which medications? 1. Escitalopram (Lexapro) and clozapine (Clozaril) 2. Citalopram (Celexa) and olanzapine (Zyprexa) 3. Lithium carbonate (Lithobid) and sertraline (Zoloft) 4. Naltrexone (ReVia) and ziprasidone (Geodon)

ANS: 3 Rationale: The SSRIs and clomipramine have been used successfully in the treatment of pathological gambling as a form of obsessive-compulsive disorder. Lithium, carbamazepine, and naltrexone have also been shown to be effective. The antipsychotic medications clozapine, olanzapine, and ziprasidone are not treatments of choice for this disorder.

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? 1. "Why do you assume responsibility for his behaviors?" 2. "I think you should start to confront his behavior." 3. "Your husband needs to deal with the consequences of his drinking." 4. "Do you understand what the term enabler means?"

ANS: 3 Rationale: The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Codependency is a typical behavior of spouses of alcoholics. Partners of clients with substance addiction must come to realize that the only behavior they can control is their own.

A client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? 1. Knowledge deficit 2. Fluid volume excess 3. Imbalanced nutrition: less than body requirements 4. Ineffective individual coping

ANS: 3 Rationale: The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? 1. Strongly encourage the client to attend 90 Alcoholics Anonymous (AA) meetings in 90 days. 2. Educate the client about the biopsychosocial consequences of alcohol abuse. 3. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. 4. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: 3 Rationale: The priority nursing intervention for this client should be to administer ordered chlordiazepoxide in a dosage according to protocol. Chlordiazepoxide is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal to reduce life-threatening complications.

1. A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

ANS: 4 Page: 419-422 Feedback 1 Exhibiting looseness of association and being euphoric is not associated with bipolar disorder. 2 Magical thinking is not associated with bipolar disorder. 3 Labile mood and delusions of reference are not associated with bipolar disorder. 4 The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one's abilities are better than everyone else's.

9. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."

ANS: 4 Page: 426 Feedback 1 The most critical challenge is not when clients can't sleep. 2 The most critical challenge is not when irritability interferes with social interactions. 3 The most critical challenge is not when clients have no insight into their problems. 4 The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped.

8. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

ANS: 4 Page: 434, 439 Feedback 1 These symptoms do not indicate consumption of foods high in tyramine. 2 These symptoms do not indicate lithium carbonate discontinuation syndrome. 3 These symptoms do not indicate development of lithium carbonate tolerance. 4 The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly with maintenance therapy to ensure proper dosage.

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

ANS: 4 Page: 435-438 Feedback 1 Zyprexa calms hyperactivity. 2 Zyprexa does not prevent extrapyramidal side effects. 3 Zyprexa does not increase the effectiveness of the immune system. 4 The nurse should explain to the client's spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder.

Which client statement demonstrates positive progress toward recovery from a substance use disorder? 1. "I have completed detox and therefore am in control of my drug use." 2. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my cravings." 3. "As a church deacon, my focus will now be on spiritual renewal." 4. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: 4 Rationale: A client who takes responsibility for the consequences of substance use disorder or substance addiction is making positive progress toward recovery. This would indicate completion of the first step of a 12-step program.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? 1. To assess for emotional strength 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for tachycardia 4. To assess for fine tremors

ANS: 4 Rationale: The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.

Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium? 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Carbamazepine (Tegretol) and donepezil (Aricept) 3. Disulfiram (Antabuse) and lorazepan (Ativan) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: 4 Rationale: The nurse should anticipate that a physician would order chlordiazepoxide and phenytoin for a client who has a history of benzodiazepine withdrawal delirium. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin is an anticonvulsant used to prevent seizures.

Which client statement indicates a knowledge deficit related to a substance use disorder? 1. "Although it's legal, alcohol is one of the most widely abused drugs in our society." 2. "Tolerance to heroin develops quickly." 3. "Flashbacks from LSD use may reoccur spontaneously." 4. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: 4 Rationale: The nurse should determine that the client has a knowledge deficit related to substance use disorders when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

. A nurse is interviewing a client in an outpatient addiction clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? 1. The client will identify one person to turn to for support. 2. The client will give up all old drinking buddies. 3. The client will be able to verbalize the effects of alcohol on the body. 4. The client will correlate life problems with alcohol use.

ANS: 4 Rationale: The nurse should expect that the client would initially correlate life problems with alcohol addiction. Acceptance of the problem is the first part of the recovery process.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during the substance induced disorder of alcohol withdrawal? 1. Antagonist therapy 2. Deterrent therapy 3. Codependency therapy 4. Substitution therapy

ANS: 4 Rationale: Various medications have been used to decrease the intensity of symptoms in an individual who is withdrawing from, or who is experiencing the effects of excessive use of, alcohol and other drugs. This is called substitution therapy and may be required to reduce the life-threatening effects of alcohol withdrawal.

15. A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1. Symptoms lasting for a minimum of two years 2. Numerous periods with manic symptoms 3. Possible comorbid diagnosis of a delusional disorder 4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode

ANS: 4, 5 Page: 420-421 Feedback 1. Symptoms last at least one year. 2. Clients have numerous periods with hypomanic episodes. 3. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. 4. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5. Depressive symptoms that do not meet the criteria for a major depressive episode.

24. A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

ANS: A A client raised in an environment that reinforces one's inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal."

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. "I am sad most of the time and I've felt this way for the last several years." B. "I find myself preoccupied with death." C. "Sometimes I hear voices telling me to kill myself." D. "I'm afraid to leave the house."

ANS: A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

ANS: A The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. The individual is experiencing psychological dependency. B. The individual is experiencing physical dependency. C. The individual is experiencing substance dependency. D. The individual is experiencing social dependency.

ANS: A The nurse should use the term "psychological dependency" to best describe this client's situation. A client is considered to be psychologically dependent on a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not." C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not." D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."

ANS: A The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food followed by purging.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.) A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

ANS: A, B The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

30. A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions.

Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.) A. "I am easily manipulated and need to work on this prior to caring for these clients." B. "Because of my father's alcoholism, I need to examine my attitude toward these clients." C. "I need to review the side effects of the medications used in the withdrawal process." D. "I'll need to set boundaries to maintain a therapeutic relationship." E. "I need to take charge when dealing with clients diagnosed with substance disorders."

ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse's ability to establish therapeutic relationships with these clients.

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? (Select all that apply.) A. "A diet rich in protein will promote hepatic healing." B. "This condition leads to a rise in serum ammonia resulting in impaired mental functioning." C. "In this condition, blood accumulates in the abdominal cavity." D. "Neomycin and lactulose are used in the treatment of this condition." E. "This condition is caused by the inability of the liver to convert ammonia to urea."

ANS: A, C The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing and that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia using neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.

28. A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

ANS: A, C, D Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post-menses

14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

ANS: B A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

ANS: B Based on Maslow's hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence, and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

27. A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action.

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

ANS: B By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

15. A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

ANS: B Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

ANS: B If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

26. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

6. What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessened the client's response to another drug.

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

ANS: B The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder.

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician? A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

29. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

8. A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimer's disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this client's symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

ANS: C Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this client's fainting to the loss of alkaline stool due to laxative abuse which would lead to a relative metabolic acidotic condition.

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this client's symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

ANS: C Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?"

ANS: C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing which is followed by inappropriate compensatory behaviors.

During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Sibutramine (Meridia) D. Pemoline (Cylert)

ANS: C The nurse should teach the client that sibutramine (Meridia) is an anorexiant medication prescribed for morbidly obese clients. The mechanism of action in the control of appetite appears to occur by inhibiting the neutotransmitters serotonin and norepinephrine. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

ANS: C The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

ANS: C The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, measurable, and also include a time frame.

16. What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular bloodwork B. The client's mood and affect score, according to the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100 mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 mL

ANS: C Twenty mg of Prozac multiplied by three results in the calculated 60 mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the rationale for scheduling group therapy at this time? A. To shift the clients' focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

ANS: C When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

7. A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

21. Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "Nothing will help me feel better."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.

25. A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

17. A client diagnosed with major depressive disorder states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's affective symptoms? A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you ever felt this way before? C. "People who have mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood.

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepan (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

3. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

Which client statement indicates a knowledge deficit related to substance abuse? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society." B. "Tolerance to heroin develops quickly." C. "Flashbacks from LSD use may reoccur spontaneously." D. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

9. A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects the underlying etiology of this disorder? A. "Skaters need to be thin to improve their daily performance." B. "All the skaters on the team are following an approved 1,200-calorie diet." C. "When I lose skating competitions, I also lose my appetite." D. "I am angry at my mother. I can only get her approval when I win competitions."

ANS: D This client statement reflects the underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family member's development of anorexia nervosa.

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. "I do not use any laxatives or diuretics to lose weight." B. "I am losing lots of hair. It's coming out in handfuls." C. "I know that I am thin, but I refuse to be fat!" D. "I don't know why people are worried. I need to lose this weight."

ANS: D When the client states, "I don't know why people are worried. I need to lose this weight," the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.

26. Order the following stages of the codependency recovery process according to Cermak. ________ The Core Issues Stage ________ The Reintegration Stage ________ The Survival Stage ________ The Reidentification Stage

ANS: The correct order is 3, 4, 1, 2 Rationale: Cermak in 1986 identified four stages in the recovery process for individuals with codependent personality: During the survival stage, the codependent must begin to let go of denial. During the reidentification stage, the individual begins to glimpse their true selves. During the core issues stage, the individual must face the fact that relationships cannot be managed by force or will. During the reintegration stage, control is achieved through self-discipline and self-confidence. 1. The Survival Stage 2. The Reidentification Stage 3. The Core Issues Stage 4. The Reintegration Stage

The concept of _______________________ arose out of a need to define the dysfunctional behaviors that are evident among members of the family of a chemically dependent person.

ANS: codependency Rationale: The concept of codependency arose out of a need to define the dysfunctional behaviors that are evident among members of the family of a chemically dependent person. The term has been expanded to include all individuals from families that harbor secrets of physical or emotional abuse, other cruelties, or pathological conditions

From which of the following symptoms might the nurse identify a chronic cocaine user? A) Clear, constricted pupils B) Red, irritated nostrils C) Muscles aches D) Conjunctival redness

ANSWER B: B) Red, irritated nostrils

Dan, who has been admitted to the alcohol rehab unit after being fired for "drinking on the job", states "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my co-workers." The defense mechanism that Dan is using is: A) Denial B) Projection C) Displacement D) Rationalization

ANSWER: A A) Denial

Mr. White is admitted to the hospital after and extended period of binge alcohol drinking. His wife reports that he has been a heavy drinker for a number of years. Lab reports reveal he has a blood alcohol level of 250mg/dL. He is placed on a chemical dependency unit for detoxification. When would the 1st signs of alcohol withdrawal symptoms be expected to occur? A) Several hours after the last drink B) 2-3 days after the last drink C) 4-5 days after the last drink D) 6-7 hours after the last drink

ANSWER: A A) Several hours after the last drink

A polysubstance user makes the statement, "The green and whites do me good after speed." How might the nurse interpret the statement? A) The client abuses amphetamines and anxiolytics B) The client abuses alcohol and cocaine C) The client is psychotic D) The client abuses narcotics and marijuana

ANSWER: A A) The client abuses amphetamines and anxiolytics

Dan begins attendance at AA meetings. Which of the statements by Dan reflects the purpose of this organization? A) "They claim they will help me stay sober" B) "I'll dry out, in AA, then I can have a social drink now and then." C) "AA is only for people who have reached the bottom." D) "If I loose my job, AA will help me find another one"

ANSWER: A A) "They claim they will help me stay sober" What Is A.A.? Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem. It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere. There are no age or education requirements. Membership is open to anyone who wants to do something about his or her drinking problem.

Dan, who has been admitted to the alcohol rehab unit after being fired for "drinking on the job", states "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my co-workers." The nurses best response is: A) "Maybe you boss is mistaken, Dan." B) "You are here because your drinking was interfering with your work, Dan" C) "Get real, Dan! You're a boozer and you know it" D) "Why do you think your boss sent you here, Dan'?

ANSWER: B B)" You are here because your drinking was interfering with your work, Dan"

Which of the following medications is the physician most likely to order for the client experiencing alcohol withdrawal syndrome? A) Haloperidol (Haldol) B) Chlordiazepoxide (Librium) C) Methadone (Dolophine) D) Phenytoin (Dilantin)

ANSWER: B B) Chlordiazepoxide (Librium) Treats anxiety, symptoms of alcohol withdrawal, and tremor. This medicine is a benzodiazepine. Side effects -Depressed mood or severe confusion, Extreme unsteadiness (trouble standing), Severe drowsiness and weakness, Slow heartbeat, Sudden mood changes, Trouble breathing, Blurred vision, headache, Diarrhea or constipation, Drowsiness, dizziness, clumsiness, Dry mouth, upset stomach, Feeling "hungover" the next morning after bedtime use, Trouble concentrating Legal status: Schedule II controlled substance, Schedule IV controlled substance Drug class: Benzodiazepine Other drugs in same class: Diazepam, Alprazolam, Lorazepam, May treat: Alcoholism, Anxiety disorder

Symptoms of alcohol withdrawal include: A) Euphoria, hyperactivity, and insomnia B) Depression, suicidal ideation, and hypersomnia C) Diaphoresis, n/v, and tremors D) Unsteady gait, nystagmus, and profound disorientation

ANSWER: C C) Diaphoresis, n/v, and tremors

Dan, who has been admitted to the alcohol rehab unit after being fired for drinking on the job. Dan's drinking buddies come for a visit, and when they leave, the nurse smells alcohol on Dan's breath. Which of the following would be the best intervention with Dan at this time? A) Search his room for evidence. B) Ask, " Have you been drinking alcohol, Dan?" C) Send a urine specimen from Dan to the lab for a drug screening. D) Tell Dan, "These guys cannot come to the unit to visit you again".

ANSWER: C C) Send a urine specimen from Dan to the lab for a drug screening.

An individual who is addicted to heroin is likely to experience which of the following symptoms of withdrawal? A) Increased heart rate and blood pressure B) Tremors, insomnia, and seizures C) Incoordination and unsteady gait D) Nausea and vomiting, diarrhea, and diaphoresis

ANSWER: D D) Nausea and vomiting, diarrhea, and diaphoresis

The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should: Apply a tourniquet to the client's arm Administer an anticonvulsant medication Ask the client if he is allergic to shellfish Apply a blood pressure cuff to the arm

Apply a blood pressure cuff to the arm applied to the client's arm prior to the initiation of ECT

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? Select one: a. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." b. "I cannot control my use of heroin. It's stronger than I am." c. "I'm going to get all my children back. They need their mother." d. "Once I deal with my childhood physical abuse, recovery should be easy."

B A client who admits that he or she is addicted to a substance and has a loss of control may have a positive prognosis. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? Select one: a. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. b. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. c. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. d. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance is exhibited when one drug results in a lessened response to another drug.

A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? Select one: a. 50 mg/dL b. 100 mg/dL c. 250 mg/dL d. 300 mg/dL

B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. When the nurse reports to the ED physician, which client symptom should be the nurse's first priority? Select one: a. Tactile hallucinations b. Blood pressure of 180/100 mm Hg c. Mood rating of 2/10 on numeric scale d. Dehydration

B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium in about the second or third day following cessation of prolonged alcohol abuse.

14. Which of the following are characteristics of a Program of Assertive Community Treatment (PACT), as described by the National Alliance on Mental Illness (NAMI)? (Select all that apply.)A. PACT offers nationally based treatment to people with serious and persistent mental illnesses. B. PACT is a type of case-management program. C. The PACT team provides services 24 hours a day, 7 days a wk, 365 dys a year. D. The PACT team provides highly individualized services directly to consumers. E. PACT is a multidisciplinary team approach.

B, C, D, E

13. Which of the following clients should a nurse recommend for a structured day program? (Select all that apply.) A. An acutely suicidal teenager B. A chronically mentally ill woman who has a history of medication non-adherence C. A socially isolated older individual D. A depressed individual who is able to contract for safety E. A client who is hearing voices that tell the client to harm others

B, E

A community health nurse is teaching a class to expectant parents. All participants lack infant care knowledge. A student nurse asks, "If you had to assign a nursing diagnosis to this group, what would it be?" What is the best nursing reply? A. "I would assign the nursing diagnosis of cognitive deficit." B. "I would assign the nursing diagnosis of knowledge deficit." C. "I would assign the nursing diagnosis of altered family processes." D. "I would assign the nursing diagnosis of risk for caregiver role strain."

B. "I would assign the nursing diagnosis of knowledge deficit."

A 27-year-old client was diagnosed 5 years ago with schizophrenia. What course of treatment should the nurse expect to be implemented? A. Eventual admission for long-term care in a psychiatric facility B. Community-based care with numerous brief hospitalizations C. Case management in the community with few relapses D. Occasional contact with outpatient counselors and psychiatrists

B. Community-based care with numerous brief hospitalizations

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? Select one: a. "Why do you assume responsibility for his behaviors?" b. "Codependency is a typical behavior of spouses of alcoholics." c. "Your husband needs to deal with the consequences of his drinking." d. "Do you understand what the term enabler means?"

C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

Upon admission to an inpatient treatment facility for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? Select one: a. Knowledge deficit b. Fluid volume excess c. Imbalanced nutrition: less than body requirements d. Ineffective individual coping

C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? Select one: a. The client is using denial by avoiding responsibility. b. The client is using displacement by blaming his wife. c. The client is using rationalization to excuse his alcohol dependence. d. The client is using reaction formation by appealing to the group for sympathy.

C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? Select one: a. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. b. Educate the client about the biopsychosocial consequences of alcohol abuse. c. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. d. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of withdrawal from substances.

While interviewing a client who abuses alcohol, the nurse learns that the client has experienced "blackouts." The wife asks what this means. What is the nurse's best response at this time? "Your husband has experienced short-term memory amnesia." "Your husband has experienced loss of remote memory." "Your husband has experienced a loss of consciousness." Your husband has experienced a fainting spell."

a "Your husband has experienced short-term memory amnesia."

A client with psychotic depression is receiving Haldol (haloperidol). Which one of the following adverse effects is associated with the use of haloperidol? Akathisia Cataracts Diaphoresis Polyuria

a Akathisa

A client on the psychiatric unit is threatening other clients and staff, and interventions to distract him have not been successful. What action should the nurse take? Call security for assistance and administer PRN medication to calm the client Tell the client to calm down and ask him again if he would like to play cards Tell the client that if he continues this behavior he will lose recreational privileges Ignore the client since it is unlikely he will actually harm anyone

a Call security for assistance and administer PRN medication to calm the client

An appropriate nursing intervention for the client with borderline personality disorder is: Observing the client for signs of depression or suicidal thinking Allowing the client to lead unit group sessions Restricting the client's activity to the assigned unit of care throughout hospitalization Allowing the client to select a primary caregiver

a Observing the client for signs of depression or suicidal thinking

A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to: Providing a supportive environment Controlling the client's feelings of anger Discussing the details of the attack Administering a hypnotic for sleep

a Providing a supportive environment

A client with a history of schizophrenia is seen in the local health clinic for medication follow-up. To maintain a therapeutic level of medication, the nurse should tell the client to avoid: Taking over-the-counter allergy medication Eating cheese and pickled foods Eating salty foods Taking over-the-counter pain relievers

a Taking over-the-counter allergy medication

A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion? Vomiting, heart rate 120, chest pain Nausea, mild headache, bradycardia Respirations 16, heart rate 62, diarrhea Temp 101°F, tachycardia, respirations 20

a Vomiting, heart rate 120, chest pain

10. Which of the following issues have been identified as contributing to the rise in the population ofthose who are homeless? (Select all that apply.) a. Poverty b. Lack of affordable health care c. Substance abuse d. Severe and persistent mental illnesse. Growth in the number of family members living together

a, b, c, d

A nurse is assessing a client diagnosed with paranoid schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of "making observations?" a. "I notice that you are talking to someone who I do not see." b. "Please tell me what they are telling you." c. Why do you continually look up at the ceiling?" d. I understand that you see someone in the hall, but I do not see anyone."

a. "I notice that you are talking to someone who I do not see." Making observations involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse's perceptions.

The client with schizophrenia is preparing for discharge. To minimize relapse, what is the most important feature of planning the client's aftercare? a. An accurate description of the medication regimen with a specific plan for obtaining refills b. Identification of three new methods of spending leisure time c. Ensuring that the client lists three potential sources of social support d. Identification of two new ways to bolster self-esteem

a. An accurate description of the medication regimen with a specific plan for obtaining refills The nurse should recognize that the most common reason patient's relapse or decompensate into their illness is because they have stopped taking their medication, so teaching should emphasize compliance with medication.

A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? a. Sore throat, fever, and malaise b. Akathesia and hypersalivation c. Akinesia and insomnia d. Dry mouth and urinary retention

a. Sore throat, fever, and malaise Intervene immediately if client experiences signs of infectious process-such as sore throat, fever, & malaise-when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection.

Which of the following represents a nursing intervention at the tertiary level of prevention? a. serving as case manager for a mentally ill homeless client b. leading a support group for newly retired men c. teaching prepared childbirth classes d. caring for a depressed widow in the hospital

a. serving as case manager for a mentally ill homeless client

Which of the following represents a nursing intervention at the primary level of prevention? a. teaching a class in parent effectiveness training b. leading a group of adolescents in drug rehab c. referring a married couple for sex therapy d. leading a support group for battered women

a. teaching a class in parent effectiveness training

The diagnosis of __________________ ___________________includes the symptoms of gross distortion of body image, preoccupation with food, and refusal to eat

anorexia nervosa

The physician has ordered Eskalith (lithium carbonate) 500mg three times a day and Risperdal (risperidone) 2mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is: The client's symptoms of acute mania are typical of undiagnosed schizophrenia. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs. The client will be more compliant with a medication that allows some feelings of hypomania.

b Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.

The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: Agnosia Apraxia Anomia Aphasia

b Apraxia

The nurse is assigning staff to care for a number of clients with emotional disorders. Which facet of care is suitable to the skills of the nursing assistant? Obtaining the vital signs of a client admitted for alcohol withdrawal Helping a client with depression with bathing and grooming Monitoring a client who is receiving electroconvulsive therapy Sitting with a client with mania who is in seclusion

b Helping a client with depression with bathing and grooming

A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 mEq/L. What behavior changes would be most common for this client? a Anger b Mania c Depression d Psychosis

b Mania

A client has a history of abusing barbiturates. Which of the following is a sign of mild barbiturate intoxication? Rapid speech Nystagmus Anisocoria Polyphagia

b Nystagmus

A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that: St. John's wort seldom relieves depression. She should avoid eating aged cheese. Skin reactions increase with the use of sunscreen. The herbal is safe to use with other antidepressants.

b She should avoid eating aged cheese.

A client with schizophrenia has become disruptive and requires seclusion to help him regain control of his behavior. Which staff member can institute seclusion? a The security guard b The registered nurse c The licensed practical nurse d The nursing assistant

b The registered nurse

Which of the following client statements would demonstrate a major symptom of schizophrenia spectrum disorder? a. "I've been depressed ever since our house was destroyed by fire." b. "You can read my mind. This light of mine will shine, fine; blinding world will end at nine." c. "I had too much to drink last night, started feeling all-powerful, and stupidly drove my truck into a tree." d. ''A stitch in time saves nine' means that prevention is easier than fixing a real problem."

b. "You can read my mind. This light of mine will shine, fine; blinding world will end at nine." The nurse should recognize this statement is a rhyming statement and is called a clang association and is a positive symptom of schizophrenia spectrum disorder.

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? a. Establishing personal contact with family members. b. Being reliable, honest, and consistent during interactions. c. Sharing limited personal information. d. Sitting close to the client to establish rapport.

b. Being reliable, honest, and consistent during interactions. The nurse can enhance the establishmt of a trusting relationship w/a client diagnosed w/schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

Ann is a psychiatric home health nurse. She has just received an order to begin regular visits to Mrs. W a 78 year old widow who lives alone. Mrs. W.'s PCP has diagnosed her as depressed. Which criteria would qualify Mrs. W for home health visits? a. Mrs W never learned to drive and hast o depend on others for her transportation b. Mrs. W is physically too weak to travel without risk of injury c. Mrs. W refuses to seek assistance as suggested by her physician "because I don't have a psychiatric problem"

b. Mrs. W is physically too weak to travel without risk of injury

Three predominant client populations have been identified as benefiting most from psychiatric home health care. Which of the following is not included among this group? a. elderly individuals b. individuals living in poverty c. individuals with severe and persistent mental illness d. individuals in acute crisis situations

b. individuals living in poverty

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the clients positive and negative symptoms of schizophrenia? a. paranoid delusions, anhedonia, an anergia or positive symptoms of schizophrenia b. paranoid delusions, neologisms, echolalia are positive symptoms of schizophrenia c. paranoid delusions, anergia, and echolalia or negative symptoms of schizophrenia d. paranoid delusions, flat effect, and anhedonia negative symptoms of schizophrenia

b. paranoid delusions, neologisms, echolalia are positive symptoms of schizophrenia

Which of the following represents a nursing intervention at the secondary level of prevention? a. teaching a class about menopause to middle-aged women b. providing support in the emergency room to a rape victim c. leading a support group for women in transition d. making monthly visits to the home of a client with schizophrenia to ensure medication compliance

b. providing support in the emergency room to a rape victim

The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time is termed ________________________.

bingeing

A client with schizophrenia spends much of his time pacing the floor, rocking back and forth, and moving from one foot to another. The client's behaviors are an example of: Dystonia Tardive dyskinesia Akathisia Oculogyric crisis

c Akathisia an extrapyramidal side effect of antipsychotic medication, results in an inability to sit still or stand still.

A client with a history of cocaine abuse is experiencing tactile hallucinations. This symptom is known as: Dyskinesia Confabulation Formication Dystonia

c Formication symptom is known as formication

A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in: One week Two weeks Four weeks Six weeks

c Four weeks

An elderly client has been noted to have increasing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing: Proprioception Agnosia Sundowning Confabulation

c Sundowning

A client with schizophrenia has been taking Thorazine (chlorpromazine) 200 mg four times a day. Which finding should be reported to the doctor immediately? The client complains of thirst. The client has gained four pounds in the past two months. The client complains of a sore throat and fever. The client naps throughout the day.

c The client complains of a sore throat and fever.

A client diagnosed with schizophrenia states, can you hear him? It's the devil. He's telling me I'm going to hell. Which is the most appropriate nursing response? a. Did you take your medicine this morning? b. You are not going to hell, you are a good person c. I'm sure the voices sound scary, but the devil is not talking to you. This is part of your illness. d. The devil only talks to people who are receptive to his influence.

c. I'm sure the voices sound scary, but the devil is not talking to you. This is part of your illness.

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? a. Tactile hallucinations b. Flat affect c. Restlessness and muscle rigidity d. Reports of hearing disturbing voices

c. Restlessness and muscle rigidity

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? a. Haloperidol (Haldol) to address the negative symptom. b. Clonazepam (Klonopin) to address the positive symptom. c. Risperidone (Risperdal) to address the positive symptom. d. Clozapine (Clozaril) to address the negative symptom.

c. Risperidone (Risperdal) to address the positive symptom. The nurse should recognize that appearing to listen to unseen others is an example of experiencing an auditory hallucination which is a positive symptom of the illness and Risperidone is an antipsychotic medication for this purpose.

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize? a. Respirations of 22 beats/minute b. Weight gain of 8 pounds in 2 months c. Temperature of 106 degrees F d. Excessive salivation

c. Temperature of 106 degrees F high temperature could be an indicator of neuroleptic malignant syndrome (NMS), a serious and potentially fatal side effect of anti-psychotic medication, notify HCP immed.

John, a homeless person, has just come to live in the shelter. The shelter nurse is assigned to his care. Which of the following is a priority intervention on the part of the nurse? a. referring John to a social worker b. Developing a plan of care for John c. conducting a behavioral and needs assessment on John d. helping John apply for social security benefits

c. conducting a behavioral and needs assessment on John

A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, "I don't know why you are all so worried; I am in control. I don't have a problem." Which defense mechanism is being utilized? Rationalization Projection Dissociation Denial

d Denial

An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help with decreasing the client's confusion by: Assigning a nursing assistant to sit with him until he falls asleep Allowing the client to room with another elderly client Administering a bedtime sedative Leaving a nightlight on during the evening and night shifts

d Leaving a nightlight on during the evening and night shifts

A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food? Roast beef Broiled fish Baked chicken Sliced pork

d Sliced pork

How can the nurse assist a newly admitted schizophrenic client to become comfortable initially, on the psychiatric unit? a. Assign him a unit responsibility. b. Allow him to stay in his room the first few days. c. Put him group therapy and introduce him to others. d. Allow him to move at his own pace.

d. Allow him to move at his own pace. The nurse should recognize that the new environment could promote fear and discomfort to this client, so allowing him to move at their own pace and not to force them into any situation that may be uncomfortable for them, will help in developing a trusting nurse-client relationship.

Immerses assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, do you receive special messages from certain sources, such as the television or radio? For which potential symptom of this disorder is the nurse assessing? a. thought insertion b. paranoid delusions c. magical thinking d. delusions of reference

d. delusions of reference

To rid the body of excessive calories, a client diagnosed with bulimia nervosa may engage in ______________________ behaviors, which include self-induced vomiting, or the misuse of laxatives, diuretics, or enemas

purging