S3U5
CAGE
Questions: Have you felt you needed to cut down on your drinking? Are people annoyed by your drinking? Have you felt guilty about your drinking? Have you ever had a drink in the morning (eye-opener)? Score of 2 or more is significant, although a score of 1 requires further assessment.
Phobia Nursing Interventions
Reduce phobic behavior -Do not force client to come in contact with the feared object or source of anxiety -Have client focus on awareness of self -Distract client's attention from phobia
Bupropion (Zyban)
an antidepressant drug, reduces the urge to smoke, reduces some symptoms of withdrawal, and helps prevent weight gain associated with smoking cessation.
AUDIT
The Alcohol Use Disorders Identification Test
Alcohol Abuse Interventions
Withdrawal (1) Reduce environmental stimuli (2) Antianxiety medications (3) Vitamin supplements (4) Seizure precautions (5) Suicide precautions (6) Fever Considerations (7) Identify support systems (8) Group therapy (9) Dilsulfiram (10) Naltrexone
Women
__________ have higher blood alcohol levels than men do after the same amount of alcohol intake.
2. Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply. a. Pupils are dilated b. Pulse rate is 62 beats/min c. Slow movements d. Extreme anxiety e. Sleepy
a. Pupils are dilated d. Extreme anxiety
Compulsions
repetitive, ritualistic behaviors that are performed in a certain fashion to relieve an unbearable amount of tension (most common include hand-washing, counting, checking)
binge drinking
the consumption of excessive amounts of alcohol at one sitting; consuming 5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion at least once per month.
An exemplar of a social/emotional developmental delay is A. developmental dyspraxia B. fragile X syndrome C. mental retardation D. separation anxiety disorder
D. separation anxiety disorder
A syndrome that occurs after stopping the long-term use of a drug is called A. amnesia. B. tolerance. C. enabling. D. withdrawal.
D. withdrawal. Withdrawal is a condition marked by physical and psychological symptoms that occur when a drug that has been taken for a long time is stopped or drastically reduced in dosage.
Hallucinations, Illusions, Delusions
Hallucination (1) No external stimulus (2) Auditory (3) Visual (4) Olfactory (5) Gustatory (6) Tactile Illusion (7) Misinterpretation of stimulus Delusion (8) Fixed, false belief
Beck's cognitive theory suggests that the etiology of depression is related to what factor?
Negative processing of information Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self-deprecating view of oneself; (2) a pessimistic view of the world; and (3) the belief that negative reinforcement will continue. None of the other options are related to this theory.
CAGE-AID
Questions are the same as CAGE but refers to Adapted to Include Drugs
Screening, Brief Intervention, Referral to Treatment (SBIRT)
A public health approach that seeks to intervene early and provide treatment for people with substance use disorders and for those at risk of developing these disorders. (Saunders)
A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? Select all that apply. A. A motivational interview B. Observing for stress reaction C. Converting narcotic use from an illicit to a legally controlled drug D. Observing for delirium tremens E. Encouraging involvement in Narcotics Anonymous
A. A motivational interview B. Observing for stress reaction E. Encouraging involvement in Narcotics Anonymous
T-ACE
Tolerance, Annoyance, Cut down, Eye-opener
10. Adolescents often display fluctuations in mood along with undeveloped emotional regulation and poor tolerance for frustration. Emotional and behavioral control usually increases over the course of adolescence due to: a. Limited executive function b. Cerebellum maturation c. Cerebral stasis and hormonal changes d. A slight reduction in brain volume
b. Cerebellum maturation
9. Maxwell is a 30-year-old male who arrives at the emergency department stating, "I feel like I am having a stroke." During the intake assessment, the nurse discovers that Maxwell has been working for 36 hours straight without eating and has consumed eight double espresso drinks and 12 caffeinated sodas. The nurse suspects: a. Fluid overload b. Dehydration and caffeine overdose c. Benzodiazepine overdose d. Sleep deprivation syndrome
b. Dehydration and caffeine overdose
Agoraphobia
fear of being in places or situations; crowds, traveling
Health problems related to cannabis use
• Bronchitis, chronic cough • Depression, anxiety, schizophrenia • Memory impairment
Health problems related to amphetamine use
• Cardiac dysrhythmias, myocardial ischemia and infarction • Liver, lung, kidney damage • Mood disturbances, violent behavior, psychoses
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise rigorously.
2. Interrupt the client and offer to take her for a walk.
Long-term alcohol use
can lead to hypertension, heart disease, stroke, liver disease, and digestive problems.
Short-term, excess alcohol use
increases the risk for injury from motor vehicle crashes, falls, firearms, assault, drowning, and burns.
Health problems related to use of inhalants (substance use)
• Cognitive and motor impairment • Acute and chronic kidney injury
Health problems related to personal neglect
• Malnutrition, impaired immunity • Accidental injuries
Substance Abuse Assessment
(1) Changes in mood (2) Poor hygiene (3) Odd sleep patterns (4) Frequent injuries (5) Relationship or job difficulty (6) Poor performance (7) Anorexia or weight loss (8) Social isolation (9) Financial problems
A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? 1. Alcohol 2. Barbiturates 3. Hallucinogens 4. Multiple drugs
1. Alcohol The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.
A 5-year-old with attention deficit-hyperactivity disorder (ADHD) exhibits a short attention span and demonstrates intermittent head-banging and hair-pulling, as well as excessive motor activity. What is the priority nursing objective for this child? 1. Facilitating sleep 2. Maintaining safety 3. Promoting body image 4. Increasing nutritional intake
2. Maintaining safety Excessive motor activity with intermittent head-banging and hair-pulling is self-destructive behavior that may result in injury; prevention of self-injury has the highest priority. Facilitating sleep, promoting body image, and increasing nutritional intake are not the most important nursing objectives in light of the data presented; prevention of self-injury is primary.
An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client's pain level? 1. Asking the client's parent 2. Using Wong's "Pain Faces" 3. Observing the client's body language 4. Explaining the use of a 0 to 10 pain scale
2. Using Wong's "Pain Faces" An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.
A client frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the client's level of anxiety as A. mild. B. moderate. C. severe. D. panic.
C. severe. Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart. Mild and moderate levels of anxiety do not demonstrate these feels while panic is even more intense than the scenario implies.
The nurse is caring for a child who has attention deficit-hyperactivity disorder (ADHD). Which changes in the child's classroom will be beneficial? Select all that apply. 1. Providing breaks frequently at regular intervals 2. Writing instructions on the blackboard after verbalization 3. Increasing the number of classroom assignments and homework 4. Improving the writing skills of the child compared with computer skills 5. Scheduling academic subjects for times when the child is under the effect of medication
1. Providing breaks frequently at regular intervals 2. Writing instructions on the blackboard after verbalization 5. Scheduling academic subjects for times when the child is under the effect of medication A child with ADHD will not be able to concentrate properly and experiences difficulty sitting in one place for a prolonged time. Therefore frequent breaks are helpful to improve the child's concentration. Visual representations also help attract attention and improve concentration. Therefore it is appropriate to write instructions after saying them. The child will have increased concentration under the effect of medication, which is generally in the morning. Therefore academic subjects should be scheduled for the morning. A child with ADHD will have dysgraphia, or poor handwriting. Therefore it is appropriate to concentrate on improving the child's computer skills, instead of improving handwriting. It is appropriate to allot more time to take tests and help the child complete tasks rather than giving homework and assignments.
What psychosocial clues should be explored to confirm substance abuse in an adolescent? Select all that apply. 1. Overly polite behavior 2. Increased school absenteeism 3. Presence of drug-oriented magazines 4. Changes in interpersonal relationships 5. Wearing light clothes despite cold weather
2. Increased school absenteeism 4. Changes in interpersonal relationships Psychosocial clues to substance abuse include increased school absenteeism and changes in interpersonal relationships. Other psychosocial clues include falling grades, changes in dress, isolation, and increased aggressiveness. Adolescents with substance abuse problems become increasingly aggressive rather than overly polite. The presence of drug-oriented magazines may indicate substance abuse, but this is an environmental clue, not a psychosocial one. Adolescents with substance abuse issues tend to wear long-sleeved shirts in hot weather.
A school nurse is asked to present an educational program on attention deficit-hyperactivity disorder (ADHD) to the teaching staff of an elementary school. What should the nurse emphasize about this disorder? 1. It becomes evident before 4 years of age. 2. It affects 3% to 7% of the school-age population. 3. It occurs more frequently in lower socioeconomic groups. 4. It causes affected children to sleep more than unaffected children.
2. It affects 3% to 7% of the school-age population. The DSM-IV-TR reports an incidence of ADHD of 3% to 7% among school-aged children. This problem usually becomes evident around 6 to 7 years of age and is noted in at least two different settings (e.g., school and home). Socioeconomic factors do not play a major role in the occurrence of this disorder. Children with ADHD have less need for sleep than do children without ADHD.
3. The most appropriate nursing intervention for a patient who is being treated for an acute exacerbation of chronic obstructive pulmonary disease who is not interested in quitting smoking is to a. accept the patient's decision and not intervene until the patient expresses a desire to quit. b. ask the patient to identify the risks and benefits of quitting and what barriers to quitting are present. c. realize that some smokers never quit, and trying to assist them increases the patient's frustration. d. motivate the patient to quit by describing how continued smoking will worsen the breathing problems.
b. ask the patient to identify the risks and benefits of quitting and what barriers to quitting are present.
manifestations of alcohol withdrawal syndrome
• Agitation • Anxiety • ↑ Heart rate • ↑ BP • Sweating • Nausea • Tremors • Insomnia • Hyperactivity
alcohol use disorder (AUD)
(alcoholism); alcohol use marked by tolerance, withdrawal, and a drive to continue problematic use; affects about 6.2% of U.S. adults.
alcohol
A preparation containing at least 92.3% and not more than 93.8% by weight of ethyl alcohol, used as a topical antiseptic and solvent. A clear, colorless, volatile liquid that is miscible with water, chloroform, or ether, obtained by the fermentation of carbohydrates with yeast. A compound derived from a hydrocarbon by replacing one or more hydrogen atoms with an equal number of hydroxyl groups. (Saunders)
Anxiety Disorders Nursing Interventions
1. Systematic desensitization/exposure therapy 2. Reciprocal inhibition 3. Cognitive therapy 4. Regular daily exercise 5. Other therapies: hypnosis, meditation, imagery, yoga, biofeedback training
Opioid Abuse and Withdrawal Assessment
Abuse Assessment (1) Euphoria (2) Miosis (3) CNS Depression Abuse Withdrawal (4) Yawning (5) Gooseflesh (6) Sweating (7) Rhinorrhea (8) Kicking movement Consideration (9) Naloxone
fetal alcohol spectrum disorders
All disorders resulting from maternal use of alcohol during pregnancy; includes fetal alcohol syndrome. (Saunders)
Wernicke's encephalopathy
An inflammatory, hemorrhagic, degenerative condition of the brain. It is characterized by lesions in several parts of the brain, double vision, opthalmoplegia, involuntary and rapid movements of the eyes, lack of muscular coordination, and decreased mental function, which may be mild or severe. Wernicke's encephalopathy is caused by a thiamine deficiency and is seen in association with chronic alcoholism. (Saunders)
An obsession is defined as what? A. Thinking of an action and immediately taking the action B. A recurrent, persistent thought or impulse C. An intense irrational fear of an object or situation D. A recurrent behavior performed in the same manner
B. A recurrent, persistent thought or impulse Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. None of the remaining statements are accurate when defining the term obsession.
A client's daughter states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." This information supports that the client may be experiencing which anxiety-related disorder? A. Panic disorder B. Adult separation anxiety disorder C. Agoraphobia D. Social anxiety disorder
B. Adult separation anxiety disorder
A client brought to the emergency department after phenylcyclohexylpiperidine (PCP) ingestion is both verbally and physically abusive. What nursing intervention should be implemented to best assure the safety of the client and the milieu? Select all that apply. A. Taking him to the gym on the psychiatric unit B. Obtaining an order for seclusion and close observation C. Assigning a psychiatric technician to "talk him down" D. Administering naltrexone as needed per hospital protocol E. Obtaining a prescription for a benzodiazepine
B. Obtaining an order for seclusion and close observation E. Obtaining a prescription for a benzodiazepine Aggressive, violent behavior is often seen with PCP ingestion. The client will respond best to a safe, low-stimulus environment such as that provided by seclusion until the effects of the drug wear off as well as the calming effect of a benzodiazepine. Talking down is never advised because of the client's unpredictable violent potential. Naltrexone is an opiate antagonist.
A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? A. Anxiety B. Seasonal affective disorder C. Medication side effects D. Antisocial personality
B. Seasonal affective disorder
Autism is a complex developmental disorder. Diagnostic criteria for autism include delayed or abnormal functioning in which area(s) before 3 years of age? (Select all that apply.) Select all that apply. A. Parallel play B. Social interaction C. Gross motor development D. Inability to maintain eye contact E. Language as used in social communication
B. Social interaction D. Inability to maintain eye contact E. Language as used in social communication Children diagnosed with autism show delayed or abnormal functioning in social interactions. A hallmark characteristic of autism is the child's inability to make and maintain eye contact. A characteristic of autism is the child's delay of language at an early age or the sudden deterioration in extant expressive speech. Parallel play is not an area in which autistic children may show delay. When interacting with other children in other forms of play they display functional limitations. Gross motor development is not an area in which autistic children show delayed or abnormal functioning.
A 72-year-old patient diagnosed with Parkinson's disease is demonstrating behaviors associated with anxiety and has had several falls lately and is reluctant to take medications as prescribed. When his provider orders lorazepam, 1 mg PO bid, the nurse questions the prescription based primarily on what fact? A. The client may become addicted faster than younger patients. B. The client is at risk for falls. C. The client has a history of nonadherence with medications. D. The client should be treated with cognitive therapies because of his advanced age.
B. The client is at risk for falls.
A child diagnosed with autism will demonstrate impaired development in which area? A. adhering to routines B. playing with other children C. swallowing and chewing D. eye-hand coordination
B. playing with other children Autism affects the normal development of the brain in social interaction and communication skills. Symptoms associated with autism spectrum disorders include significant deficits in social relatedness, including communication, nonverbal behavior, and age-appropriate interaction. Other behaviors include stereotypical repetitive speech, obsessive focus on specific objects, over adherence to routines or rituals, hyper- or hypo-reactivity to sensory input, and extreme resistance to change. None of the other options are characteristically associated with autism.
A teaching need is revealed when a client taking disulfiram (Antabuse) states: A. "I usually treat heartburn with antacids." B. "I take ibuprofen or acetaminophen for headache." C. "Most over-the-counter cough syrups are safe for me to use." D. "I have had to give up using aftershave lotion."
C. "Most over-the-counter cough syrups are safe for me to use." The client taking disulfiram has to avoid hidden sources of alcohol. Many cough syrups contain alcohol. The remaining statements are correct.
Assessment of the thought processes of a client diagnosed with depression is most likely to reveal what characteristic? A. Good memory and concentration B. Delusions of persecution C. Self-deprecatory ideation D. Sexual preoccupation
C. Self-deprecatory ideation Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world. This characteristic is not associated with any of the other options.
Which medication is FDA approved for treatment of anxiety in children? A. Sertraline B. Fluoxetine C. Clomipramine D. Duloxetine
D. Duloxetine
A client has a 4 year history of using cocaine intranasally. When brought to the hospital in an unconscious state, what nursing measure should be included in the client's plan of care? A. Induction of vomiting B. Administration of ammonium chloride C. Monitoring of opiate withdrawal symptoms D. Observation for tachycardia and seizures
D. Observation for tachycardia and seizures Tachycardia and convulsions are dangerous symptoms seen in central nervous system stimulant overdose. None of the other options are associated with the nursing care required of cocaine stimulation.
A 10-year-old who is frequently disruptive in the classroom begins to fidget and then moves on to disruptive behavior. What is the most appropriate initial technique for managing this sort of disruptive behavior? A. Therapeutic holding B. Seclusion C. Quiet room D. Touch control
D. Touch control The appropriate adult can move closer to the child and place a hand on his/her arm or an arm around his/her shoulder for a calming effect when the fidgeting is first noted. The closeness signals the child to use self-control. It is the least restrictive treatment approach and should be tried initially; before any of the other options.
Down Syndrome
Pathophysiology (1) Trisomy 21 (2) Meiotic nondisjunction Signs and Symptoms (3) Intellectual disability (mental retardation) (4) Simian crease (5) Flat facies (6) Duodenal atresia (7) Hirschsprung's disease (8) Septum primum type ASD (9) Endocardial cushion defects (10) Prominent epicanthal folds (11) Increased risk of acute lymphoblastic leukemia (12) Alzheimer's disease
Depression Assessment
Physical changes: (1) Anergia (2) Self-neglect (3) Decreased libido (4) Vegetative signs Mood: (5) Sad affect (6) Worthlessness (7) Guilt (8) Anger and irritability Cognitive: (9) Ineffective problem solving (10) Slow thinking
CNS Stimulants Side Effects
Side Effects (1) Angina (2) Insomnia (3) Hypertension (4) Tachycardia (5) Tics (6) Anorexia Considerations (7) Tolerance Develops (8) High risk of abuse and dependence
electronic cigarettes
a cigarette-shaped device containing a nicotine-based liquid that is vaporized and inhaled, used to simulate the experience of smoking tobacco
Varenicline (Chantix)
a drug used to aid smoking cessation. unique in that it has both agonist and antagonist actions. Its agonist activity at 1 subtype of nicotinic receptors provides some nicotine effects to ease withdrawal symptoms. If the person does resume smoking, its antagonist action blocks the effects of nicotine at another subtype of nicotinic receptor, making smoking less enjoyable.
tobacco use disorder (TUD)
a problematic pattern of tobacco use leading to clinically significant impairment or distress
Phobia
an intense, irrational fear of a specific object, activity, or situation
2. Which activity is most appropriate for a child with ADHD? a. Reading an adventure novel b. Monopoly c. Checkers d. Tennis
d. Tennis
acute alcohol toxicity
occurs when a person has a high level of alcohol in the blood, generally after ingesting a large amount of alcohol. This leads to behavior changes and alcohol-induced CNS depression, resulting in respiratory and circulatory failure. Unconsciousness, coma, and death can occur. Other common effects include hypokalemia, hypomagnesemia, and hypoglycemia.
stimulant toxicity
patients present with sympathetic overdrive. The patient has restlessness, agitation, delirium, impaired judgment, and paranoia with psychotic symptoms. Physical effects include hypertension, tachycardia, fever, pupil dilation, seizures, confusion, and diaphoresis. Death may occur from stroke, dysrhythmias, or myocardial infarction.
Obsessions
recurrent, persistent ideas, thoughts, or impulses that are not voluntarily produced (most common include thoughts of violence, need for order, contamination, and doubt)
alcohol withdrawal symptoms
tremors, fatigue, anxiety, abdominal cramping, hallucinations, confusion, seizures, delirium
Obsessive-compulsive disorder
unconscious control of anxiety by the use of rituals, thoughts, obsessions, or compulsions
ADHD Nursing Interventions
• Behavior modification • Special education programs • Psychotherapy • Play therapy • Pharmaceutical agents
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2. "What do you find difficult about this situation?" 3. This is not the best time to make that decision." 4. I agree with you. You should get out of this situation."
2. "What do you find difficult about this situation?"
Which factor can reduce the vulnerability of a child to etiological influences predisposing to the development of psychopathology? A. Resilience B. Malnutrition C. Child abuse D. Having a depressed parent
A. Resilience Resilience refers to developing and using certain characteristics that help a child to handle the stresses of a difficult childhood without developing mental problems. Resilient children can adapt to changes in the environment, form nurturing relationships with adults other than their parents, distance themselves from the emotional chaos of the family, and have social intelligence and the ability to use problem-solving skills.
The patient describes their needing a larger dose of an illicit drug to get the same effect. How should the nurse document this patient's usage? A. Tolerance B. Addiction C. Substance use D. Substance dependence
A. Tolerance Tolerance is the need for a larger dose of drug to obtain the original effect. Addiction is compulsive, uncontrollable dependence on a substance such that cessation causes severe emotional, mental, or physiologic reactions. Substance abuse is overindulgence in a substance that has a negative impact on the psychologic, physiologic, or social functioning of the person. Substance dependence is such reliance on a substance that the absence of the substance will cause impairment in function.
Obsessive-Compulsive Disorder (OCD)
Assessment (1) Repetitive and intrusive thoughts (2) Suppressed by thought or action (3) Interferes with daily functioning (4) May or may not be aware Interventions (5) Cognitive behavioral therapy (CBT) (6) Selective serotonin reuptake inhibitors (SSRIs) (7) Clomipramine (8) Venlafaxine
A 7-year-old, who is described as impulsive and hyperactive, tells the nurse, "I am a dummy, because I don't pay attention, and I can't read like the other kids." The nurse notes that these behaviors are most consistent with which diagnosis? A. Attention deficit disorder B. Attention deficit hyperactivity disorder C. Autism D. Conduct disorder
B. Attention deficit hyperactivity disorder The data are most consistent with attention deficit hyperactivity disorder (ADHD) as described in the DSM-5. The other options present with characteristics and behaviors that differ from those in the scenario.
A client is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the client reports which information? A. Symptoms started right after being robbed at gunpoint. B. Being unable to work for the last 12 months. C. Eating in public makes the client extremely uncomfortable. D. Repeated verbalizing prayers results in a relaxed feeling.
B. Being unable to work for the last 12 months. GAD is characterized by symptomatology that lasts 6 months or longer. None of the other descriptions would support the diagnosis.
A patient arrives to the emergency department with a reported overdose of diazepam (Valium). Which medication would the nurse prepare to administer as an antidote? A. Naloxone B. Flumazenil C. Phytonadione D. Protamine sulfate
B. Flumazenil Flumazenil reverses the effects of benzodiazepines, such as diazepam, by acting as a competitive antagonist at gamma-aminobutyric acid (GABA)-benzodiazepine receptor sites. Protamine sulfate reverses the anticoagulant effects of heparin. Naloxone is an opioid antagonist and used with opioid overdose. Phytonadione is vitamin K and is used for hypoprothrombinemia caused by anticoagulants such as warfarin.
The parents of a cognitively impaired child ask the nurse for guidance with discipline. The nurse's BEST response is: A. "Discipline is ineffective with cognitively impaired children." B. "Discipline is not necessary for cognitively impaired children." C. "Behavior modification is an excellent form of discipline." D. "Physical punishment is the most appropriate form of discipline."
C. "Behavior modification is an excellent form of discipline." Behavior modification with positive reinforcement is effective in children with cognitive impairment. Discipline is essential in assisting the child in developing boundaries. Positive behaviors and desirable actions should be reinforced. Most children with cognitive impairment will not be able to understand the reason for the physical punishment; consequently behavior will not change as a result of the punishment.
The nurse is providing care for a patient admitted with alcohol withdrawal delirium. Which intervention should be the first priority for the nurse? A. Applying physical restraints B. Reorienting the patient frequently C. Asking the patient about his last alcohol intake D. Scoring the patient using a symptom assessment tool
C. Asking the patient about his last alcohol intake Management begins with identifying at-risk people. Use a symptom assessment tool, such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). Physical restraints are rarely necessary if drugs administered during withdrawal are appropriately used. Information about treatment for alcohol dependency is not appropriate at this acute stage.
Anxiety Assessment
Mild: (1) Increased alertness (2) Heightened perception Moderate: (3) Perception narrowed (4) Short attention span (5) Shaking Severe: (6) Ineffective problem solving (7) Automatic behavior (8) Hyperventilation Panic: (9) Hallucinations (10) Inability to function or communicate
5. A patient diagnosed with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success? a. Restrict visitors to family members only. b. Manage the patient's withdrawal symptoms well. c. Provide the patient a low stimulus environment. d. Advocate for at least 3 months of treatment.
b. Manage the patient's withdrawal symptoms well.
Health problems related to use of sedative-hypnotics (substance use)
• Memory impairment • Personality changes, depression
Benzodiazepine Intoxication Assessment
(1) Drowsiness (2) Confusion (3) Respiratory depression (4) Hypotension (5) Coma Treatment (6) Flumazenil (Romazicon)
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? SATA. 1. Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range
1. Dental decay 3. Loss of tooth enamel 4. Electrolyte imbalances
ADHD Nursing Interventions (Zerwekh)
1. Keep child from harming self or others 2. Encourage age-appropriate, socially acceptable coping skills 3. Decrease anxiety and increase self-esteem 4. Administer prescribed medication
Down Syndrome Nursing Interventions
1. Promote optimal development 2. Encourage early identification of DS
Brief Intervention
A nurse or other healthcare professional focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
Referral to Treatment
A nurse or other healthcare professional provides those identified as needing more extensive treatment with access to specialty care.
Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? A. Onset of action is from 1 to 3 weeks or longer. B. They tend to be more effective for men. C. Recent memory impairment is commonly observed. D. They often cause the client to have diurnal
A. Onset of action is from 1 to 3 weeks or longer. A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. None of the other options provide correct information regarding antidepressant medications.
Inability to leave one's home because of avoidance of severe anxiety suggests the existence of which anxiety disorder? A. Panic attacks with agoraphobia B. Obsessive-compulsive disorder C. Posttraumatic stress response D. Generalized anxiety disorder
A. Panic attacks with agoraphobia Panic disorder with agoraphobia is characterized by recurrent panic attacks combined with agoraphobia. Agoraphobia involves intense, excessive anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred. None of the other options are associated with this form of anxiety.
When admitting a patient to the emergency department who reports chest pain, which assessment findings would alert the nurse to possible cocaine use? (Select all that apply.) A. Tachycardia B. Restlessness C. Hypotension D. Hyperthermia E. Constricted pupils
A. Tachycardia B. Restlessness C. Hypotension D. Hyperthermia Pupil dilation and restlessness occur from the nervous system stimulation by the stimulant cocaine. The nurse should suspect stimulant drug use in any patient seeking health care who has tachycardia, hyperactivity, fever, or behavioral abnormalities.
Cocaine exerts which of the following effects on a client? A. Stimulation after 15 to 20 minutes B. Stimulation and euphoria C. Immediate imbalance of emotions D. Paranoia
B. Stimulation and euphoria Cocaine exerts two main effects on the body, both anesthetic and stimulant.
When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should A. question the physician's order because the dose is excessive. B. explain the long-term nature of benzodiazepine therapy. C. teach the client to limit caffeine intake. D. tell the client to expect mild insomnia.
B. explain the long-term nature of benzodiazepine therapy. Caffeine is an antagonist of antianxiety medication. None of the other options present accurate information regarding lorazepam.
Delusionary thinking is a characteristic of which form of anxiety? A. Chronic anxiety B. Acute anxiety C. Severe anxiety D. Panic level anxiety
D. Panic level anxiety Panic level anxiety is the most extreme level and results in markedly disturbed thinking greater than in any of the other options.
The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern that the nurse should address for this patient? A. Promoting at least 6 hours of sleep a night B. Encouraging an oral intake of 1200 calories per day C. Managing the patient's pain from arthritis D. Supervising medication administration
D. Supervising medication administration
Risky drinking
consuming more alcohol than the amounts in guidelines established by the National Institute on Alcohol Abuse and Alcoholism
8. Terry is a young male in a chemical dependency program. Recently he has become increasingly distracted and disengaged. The nurse concludes that Terry is: a. Bored b. Depressed c. Bipolar d. Not ready to change
d. Not ready to change
Health problems related to risky sexual behavior
• HIV/AIDS • Hepatitis B and C • Sexually transmitted infections
Cocaine Intoxication Assessment
(1) Euphoria (2) Delusions (3) Mydriasis (4) Hallucinations (5) Agitation (6) Hypertension (7) Arrhythmias (8) Hyperthermia (9) Seizures (10) Nasal septum perforation
Amphetamines Intoxication Assessment
(1) Euphoria (2) Insomnia (3) Mydriasis (4) Diaphoresis (5) Hypertension (6) Tachycardia (7) Paranoia (8) Anxiety (9) Anorexia (10) Seizures
Marijuana Intoxication Assessment
(1) Euphoria (2) Slowed reaction time (3) Conjunctival injection (4) Increased appetite (5) Anxiety (6) Social withdrawal (7) Paranoid delusions
nicotine replacement agents
(OTC) nicotine gum, nicotine lozenge, nicotine patch (prescription) nicotine nasal spray, nicotine inhaler
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime
2. A client undergoing diagnostic tests
blood alcohol concentration (BAC)
Also called blood alcohol level (BAL); the amount of alcohol in the blood, commonly expressed as grams of alcohol per 100 milliliters of blood. Most state legal limits of intoxication while driving are 0.08% or 0.1%. (Saunders)
A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? Select all that apply. A. The patient states, "I don't think my body will recover from the drinking." B. The patient states, "I will watch the game at my friend's house instead of at the bar." C. The patient states, "I now realize that the drinking has affected by family life." D. The patient states, "I am glad that I did not drag others into my drinking." E. The patient states, "I have been attending one meeting a day."
B. The patient states, "I will watch the game at my friend's house instead of at the bar." C. The patient states, "I now realize that the drinking has affected by family life." E. The patient states, "I have been attending one meeting a day."
A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? A. Intoxication B. Tolerance C. Withdrawal D. Addiction
B. Tolerance Tolerance is described as needing increasing greater amounts of a substance to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect. Intoxication is the effect of the drug. Withdrawal is a set of symptoms patients experience when they stop taking the drug. Addiction is loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.
Which nursing diagnosis should be considered for a child with attention deficit hyperactivity disorder ADHD? A. anxiety B. risk for injury C. defensive coping D. impaired verbal communication
B. risk for injury The child's marked hyperactivity puts him or her at risk for injury from falls, bumping into objects, impulsively operating equipment, pulling heavy objects off shelves, and so forth.
A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? A. "It helps your mood so that you don't feel the need to do drugs." B. "It will keep you from experiencing flashbacks." C. "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." D. "It helps prevent relapse by reducing drug cravings."
D. "It helps prevent relapse by reducing drug cravings." Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. None of the other options do not accurately describe the action of naltrexone.
Attention-Deficit Hyperactivity Disorder (ADHD) Interventions
Drug Therapy (1) CNS stimulants (2) Amphetamine (3) Methylphenidate (4) Bupropion (Wellbutrin) (5) Atomoxetine (Strattera) (6) Guanfacine (Intuniv) Considerations (7) Manage disruptive behavior (8) Provide simple instructions
Tricyclic Antidepressants (TCAs) Indications
Indications (1) Major depression (2) Bed wetting (3) Fibromyalgia (4) OCD Drugs (5) -iptyline or -ipramine suffix (6) Amitriptyline (7) Desipramine (8) Clomipramine (9) Imipramine (10) Nortriptyline
Opioids Overview
Indications (1) Pain (2) Weaning (3) Cough (4) Diarrhea Mechanism of Action (5) Agonists at Mu, Kappa, and Delta receptors (6) Decrease synaptic transmission Side Effects (7) Respiratory depression (8) Addiction (9) Miosis (10) Constipation
Alcohol Abuse Assessment
Intoxication (1) CNS Depression Withdrawal (2) Wernicke-Korsakoff Syndrome Medical Complications (3) GI distress (4) Cardiomyopathy (5) Pancreatitis (6) Cirrhosis (7) Immunosuppression (8) Sexual dysfunction Considerations (9) Screening assessments - CAGE or AUDIT
Play therapy
a type of intervention that allows children to express feelings such as anxiety, self-doubt, and fear through the natural use of play. It is also useful in helping young patients to access and work through painful memories.
1. Which statement demonstrates a well-structured attempt at limit setting? a. "Hitting me when you are angry is unacceptable." b. "I expect you to behave yourself during dinner." c. "Come here, right now!" d. "Good boys don't bite."
a. "Hitting me when you are angry is unacceptable."
4. What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder? a. Accompany the staff member when she is giving patient care. b. Offer to attend rehabilitation counseling with her. c. Refer her to a peer assistance program. d. Confront her about your concerns and/or report your concerns to a supervisor immediately.
d. Confront her about your concerns and/or report your concerns to a supervisor immediately.
stimulant toxicity interventions
• Ensure patent airway. • Establish IV access and start appropriate fluid replacement. • Obtain a 12-lead ECG and start ECG monitoring. • Treat ventricular dysrhythmias as needed. • Treat hypertension and chest pain with nitrates or calcium channel blockers. • Aspirin may be given to lower the risk for myocardial infarction. • Give IV diazepam or lorazepam for seizures. • Give IV antipsychotic drugs for psychosis and hallucinations. • Monitor vital signs and level of consciousness. • Begin cooling measures for hyperthermia. • Treat insomnia with trazodone, hydroxyzine, or diphenhydramine at bedtime. • Start gastric lavage in cases of recent ingestion.
Varenicline (Chantix) and Bupropion (Zyban)
• Serious neuropsychiatric symptoms such as changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide can occur. • Tell patients to stop taking these drugs and contact the HCP at once if they have any of these manifestations.
8. Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his "nice" mom, that he loves school, and gets above average grades. The strongest explanation of this response is: a. Temperament b. Genetic factors c. Resilience d. Paradoxical effects of neglect
c. Resilience
7. Opioid use disorder is characterized by: a. Lack of withdrawal symptoms b. Intoxication symptoms of pupillary dilation, agitation, and insomnia c. Tolerance d. Requiring smaller amounts of the drug to achieve a high over time
c. Tolerance
6. Substance use problems in older adults are usually related to a. use of drugs and alcohol as a social activity. b. continuing the use of illegal drugs started during middle age. c. misuse of prescribed and over-the-counter medications and alcohol. d. a pattern of binge drinking for weeks or months with periods of sobriety.
c. misuse of prescribed and over-the-counter medications and alcohol.
substance use disorder (SUD)
continued substance craving and use despite significant life disruption and/or physical risk; Complex diseases of the brain represented by drug use, craving, and seeking regardless of consequences. (Saunders)
Phencyclidine (PCP) Intoxication Assessment
(1) Violent behavior (2) Motor issues (3) Nystagmus (4) Increased pain tolerance (5) Tachycardia (6) Delirium (7) Psychosis (8) Seizures
Fetal Alcohol Syndrome
The leading cause of intellectual disability in the United States. Alcohol during pregnancy inhibits intrauterine growth and postnatal development resulting in microcephaly, craniofacial malformations, and limb and heart defects. As adults, affected individuals tend to have a short stature. Women with alcohol-related disorders have a 35% risk of having a child with defects.
4. What assessment question should the nurse ask when attempting to determine a teenager's mental health resilience? Select all that apply. a. "How did you cope when your father deployed with the Army for a year in Iraq?" b. "Who did you go to for advice while your father was away for a year in Iraq?" c. "How do you feel about talking to a mental health counselor?" d. "Where do you see yourself in 10 years?" e. "Do you like the school you go to?"
a. "How did you cope when your father deployed with the Army for a year in Iraq?" b. "Who did you go to for advice while your father was away for a year in Iraq?" d. "Where do you see yourself in 10 years?"
6. Pam, the nurse educator, is teaching a new nurse about seclusion and restraint. Order the following interventions from least (1) to most (5) restrictive: a. With the patient identify the behaviors that are unacceptable and consequences associated with harmful behaviors b. Placing the patient in physical restraints c. Allowing the patient to take a time-out and sit in his or her room d. Offering a PRN medication by mouth e. Placing the patient in a locked seclusion room
(1) a. With the patient identify the behaviors that are unacceptable and consequences associated with harmful behaviors (2) d. Offering a PRN medication by mouth (3) c. Allowing the patient to take a time-out and sit in his or her room (4) e. Placing the patient in a locked seclusion room (5) b. Placing the patient in physical restraints
The nurse determines that the wife of an alcoholic client is benefiting from attending an AL-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know the are the common among alcoholics."
1. "I no longer feel that I deserve the beatings my husband inflicts on me."
5 A's (for users who want to quit)
1. Ask: Identify all tobacco users at every contact. 2. Advise: Strongly urge all tobacco users to quit. 3. Assess: Determine willingness to make a quit attempt. 4. Assist: Develop a plan with the patient to help the patient quit (e.g., counseling, medication). 5. Arrange: Schedule follow-up contact.
Panic disorder (with or without agoraphobia) Nursing Interventions
1. Reduce panic level anxiety feelings by reinterpreting the feelings correctly -Stay with the client; maintain a calm manner and use simple, direct statements -Reduce environmental stimuli (lights, noise alarms)
Which assessment finding is associated with depression? 1. The client has islands of intact memory. 2. The client has impaired recent and remote memory. 3. The client has impaired recent and immediate memory. 4. The client needs step-by-step instructions for simple tasks.
1. The client has islands of intact memory. Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory. A client with dementia has impaired recent and remote memory. The onset of delirium may be abrupt, causing impaired recent and immediate memory. A client with delirium is forgetful and requires step-by-step instructions to complete simple tasks.
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply. 1. Thin upper lip 2. Wide-open eyes 3. Small upturned nose 4. Larger-than-average head 5. Smooth vertical ridge in the upper lip
1. Thin upper lip 3. Small upturned nose 5. Smooth vertical ridge in the upper lip The abnormal facial characteristics associated with FAS include: a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, as well as microcephaly (head circumference less than the tenth percentile), rather than a larger-than-average head.
What should the nurse do when talking with a client with a history of panic disorder who is displaying many of the emotional and physiologic symptoms of a panic attack? 1. Use short sentences and an authoritative voice. 2. Describe the possible reasons for the client's anxiety. 3. Keep asking questions, because the client is probably not going to volunteer much information. 4. Suggest that the client refrain from crying, because most of the time crying makes matters worse.
1. Use short sentences and an authoritative voice. During a panic attack the attention span is shortened, making it difficult to follow long sentences. An authoritative voice lets the client know that the nurse is in control of the situation; the client is unable to set controls because of the anxiety level. Describing to the client the possible reasons for the anxiety may increase the client's anxiety level further. Asking questions may increase the client's anxiety level further. Crying is an outlet and should not be discouraged; telling someone not to cry usually worsens the crying and the anxiety.
Which sedative-hypnotics are used to treat insomnia effects associated with a panic disorder? Select all that apply. 1. Phenelzine 2. Paroxetine 3. Alprazolam 4. Imipramine 5. Clonazepam
3. Alprazolam 5. Clonazepam Alprazolam and clonazepam are examples of benzodiazepines, a class of sedative-hypnotics used to treat clients with insomnia effects associated with panic disorders. Phenelzine is a monoamine oxidase inhibitor used to treat panic disorders and promote sleep. Paroxetine is a selective serotonin reuptake inhibitor used to treat panic disorders and promote sleep. Imipramine is a tricyclic antidepressant used to treat panic disorders and promote sleep.
When a nurse assesses the style of behavior a child habitually uses to cope with the demands and expectations of the environment, he or she is assessing characteristic? A. Temperament B. Resilience C. Vulnerability D. Cultural assimilation
A. Temperament Temperament is the behavior the child habitually uses to cope with the environment. It is a constitutional factor thought to be genetically determined. It may be modified by the parent-child relationship. None of the other options would reflect this characteristic.
A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply. 1. Lack of appetite 2. Depressed mood 3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others
3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others Perseveration (repetition of a behavior pattern) is commonly demonstrated by children with autism; this behavior provides comfort. Self-stimulation through injurious behavior is associated with autism. Children with autism have difficulty communicating or do not communicate at all with others. There may be unusual eating habits and food preferences, but lack of appetite is not associated with autism. Mood disorders are usually not associated with autism.
While walking to the examination room with the nurse, a toddler with autism suddenly runs to the wall and starts banging the head on it. What should the nurse's initial action be? 1. Allowing the toddler to act out feelings 2. Asking the toddler to stop this behavior 3. Restraining the toddler to prevent head injury 4. Telling the toddler that the behavior is unacceptable
3. Restraining the toddler to prevent head injury The child with autism needs protection from self-injury. Permitting the child to act out is possible only if the acting out does not place the child in jeopardy. The child with autism has difficulty following directions, especially when out of control. The child with autism cannot separate self from behavior; a punitive approach will decrease the child's self-esteem.
The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties? 1. Receding jaw 2. Brain damage 3. Tongue thrust 4. Nasal congestion
3. Tongue thrust Tongue extrusion, a reflex response that occurs when the tip of the tongue is touched, is characteristic of infants with Down syndrome and interferes with feeding; this reflex disappears around 4 months of age. A receding jaw does not interfere with suckling. Down syndrome is caused by a chromosomal defect, not brain damage; the feeding problem is related to the chromosomal defect. Nasal congestion is not a characteristic associated with newborns with Down syndrome.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations
4. Hypertension, changes in level of consciousness, hallucinations
fetal alcohol syndrome (FAS)
A set of congenital psychologic, behavioral, and physical abnormalities that tend to appear in infants whose mothers consumed alcohol during pregnancy. It is characterized by typical craniofacial and limb defects, cardiovascular defects, intrauterine growth retardation, and retarded development. The most serious cases have involved infants born to mothers who were chronic alcoholics and drank heavily during pregnancy, but it is not known whether there is a lower limit to alcohol consumption during pregnancy or a particular period in embryonic life when the offspring is most vulnerable to effects of alcohol. (Saunders)
The nurse is assessing a patient using the CAGE questionnaire. The nurse suspects possible alcoholism when the patient makes which of the following statements? Select all that apply. A. The patient states, "My wife keeps nagging me about my drinking." B. The patient states, "I am going to try to cut down on drinking. I have been partying too much." C. The patient states, "I go to meetings once or twice a week but continue to drink." D. The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." E. The patient says to the nurse, "I am ashamed of how much I have been drinking lately." F. The patient states, "I can quit whenever I want to."
A. The patient states, "My wife keeps nagging me about my drinking." B. The patient states, "I am going to try to cut down on drinking. I have been partying too much." D. The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." E. The patient says to the nurse, "I am ashamed of how much I have been drinking lately."
When caring for a patient with acute intoxication and a history of chronic alcohol use, the nurse will anticipate administering which drug? A. Thiamine B. Naloxone C. Flumazenil D. Morphine sulfate
A. Thiamine Patients with alcohol intoxication may have hypoglycemia, decreased serum magnesium, and other signs of malnutrition. For this reason, they may be treated with intravenous (IV) glucose, magnesium sulfate, and multivitamins. IV thiamine may be given before or with IV glucose solutions to prevent Wernicke-Korsakoff syndrome, which can cause seizures and brain damage. Flumazenil (Romazicon) is the reversal agent for benzodiazepines, and naloxone is the reversal agent for opioids. The administration of an opioid analgesic (morphine) is not indicated.
Nursing assessment of an alcohol-dependent client 6 to 8 hours after the last drink would most likely reveal the presence of which early sign of alcohol withdrawal? A. Tremors B. Seizures C. Blackouts D. Hallucinations
A. Tremors Tremors are an early sign of alcohol withdrawal. The remaining options are not events considered early signs of alcohol withdrawal.
A 9-year-old patient has been diagnosed with an intellectual development disorder (IDD). Which assessment findings support this diagnosis? Select all that apply. A. Unable to explain the phrase, "Raining cats and dogs" B. Reads below age level C. Is capable of providing effective oral self care D. Enjoy interacting with developmentally similar peers E. Physically lashes out when frustrated
A. Unable to explain the phrase, "Raining cats and dogs" B. Reads below age level E. Physically lashes out when frustrated
The nurse is caring for a patient on day 1 post surgical procedure. The patient becomes visibly anxious and short of breath, and states, "I feel so anxious! Something is wrong!" What action should the nurse take initially in response to the patient's actions? A. Reassure the patient that what they are feeling is normal anxiety and do deep breathing exercises with her. B. Use the call light to inquire whether the patient has been prescribed prn anxiety medication. C. Call for staff help and assess the client's vital signs. D. Reassure the patient that you will stay until the anxiety subsides.
C. Call for staff help and assess the client's vital signs.
Attention-Deficit Hyperactivity Disorder (ADHD) Assessment
Assessment (1) Inattention (2) Incomplete tasks (3) Easily distracted (4) Hyperactivity (5) Impulsiveness (6) Disruptive Considerations (7) Two areas of life (8) Onset by age 12 (9) Symptoms > 6 months
Obsessive-compulsive disorder Nursing Interventions
Assist in coping with the compulsive behavior -Accept rituals and avoid punishment or criticism; do not interrupt ritual, because this will increase anxiety -Plan for extra time because of slowness and client's need for perfection -Prevent physical deterioration or harm, and set limits only to prevent harmful acts (such as handwashing so excessively that it removes skin from the hand surface) Encourage client to develop different ways of handling anxiety -Reduce demands on the individual -Convey acceptance of the client, regardless of behavior -Encourage alternate activity
Which statement is true regarding substance addiction and medical comorbidity? A. Most substance abusers do not have medical comorbidities. B. There has been little research done regarding substance addiction disorders and medical comorbidity. C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. D. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.
The diagnosis of cognitive impairment is based on the presence of: A. intelligence quotient (IQ) of 75 or less. B. IQ of 70 or less. C. subaverage intellectual functioning, deficits in adaptive skills, and onset at any age. D. subaverage intellectual functioning, deficits in adaptive skills, and onset before 18 years of age.
D. subaverage intellectual functioning, deficits in adaptive skills, and onset before 18 years of age. Intelligence quotient (IQ) is only one component of the diagnosis of cognitive impairment. IQ is only one component of the diagnosis of cognitive impairment. The onset of the deficit must be before age 18 to meet the diagnosis of cognitive impairment. The diagnosis of cognitive impairment has these components, including an onset before age 18.
A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold; that "He is like a rag doll. He does not cuddle up to me like my other babies did." The nurse's best interpretation of this lack of clinging or molding is that it is: A. a sign of maternal deprivation. B. a sign of detachment and rejection. C. suggestive of autism associated with Down syndrome. D. the result of the physical characteristics of Down syndrome.
D. the result of the physical characteristics of Down syndrome. Mothers may have difficulty forming attachment to their children because of these characteristics of Down syndrome. The nurse should recommend swaddling and wrapping the baby before picking him or her up. Mothers may have difficulty forming attachment to their children because of these characteristics of Down syndrome. The nurse should recommend swaddling and wrapping the baby before picking him or her up. Autism is not associated with Down syndrome. This lack of clinging is a result of the muscle hypotonicity and hyperextensibility of the joints associated with Down syndrome.
CNS Stimulants
Indications (1) Attention Deficit Hyperactivity Disorder (2) Obesity Mechanism of Action (3) Increase catecholamines at synaptic cleft (4) Increase norepinephrine (5) Increase dopamine Drug Names (6) Methylphenidate (Ritalin) (7) Methamphetamine Side Effect (8) Potential for abuse
alcoholism
The extreme dependence on excessive amounts of alcohol, associated with a cumulative pattern of deviant behaviors. Alcoholism is a chronic illness with a slow, insidious onset, which may occur at any age. The most frequent medical consequences of alcoholism are CNS depression and cirrhosis of the liver. (Saunders)
The nurse assessing a newborn suspects Down syndrome. Which characteristics support this conclusion? Select all that apply. 1. Hypotonia 2. High-pitched cry 3. Rocker-bottom feet 4. Epicanthal eye folds 5. Singe transverse palmar crease
1. Hypotonia 4. Epicanthal eye folds 5. Singe transverse palmar crease Hypotonia is typical of newborns with Down syndrome. Their muscle tone is flaccid; they have less control of the head than a healthy newborn does because of their weak muscles. The single crease across the palm of the hand is typical of newborns with Down syndrome. Epicanthal eye folds give the newborn with Down syndrome the typical slant-eyed appearance. A high-pitched cry is characteristic of newborns with brain damage, cerebral irritability (opioid withdrawal), and cerebral edema (hydrocephaly). Rocker-bottom feet are found in newborns with trisomy 18.
The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol spectrum disorder (FASD) in the newborn? Select all that apply. 1. Hypotonia 2. Polydactyly 3. Umbilical hernia 4. Hypoplastic maxilla 5. Small, upturned nose
1. Hypotonia 4. Hypoplastic maxilla 5. Small, upturned nose Hypotonia is associated with FASD as well as with Down syndrome. A receding chin (hypoplastic maxilla) is associated with FASD. The typical facies associated with FASD also usually includes a small, upturned nose, which is distinctive in these infants. Polydactyly (extra fingers) is associated with the trisomies. An umbilical hernia can develop in early infancy and is not related to FASD.
Methylphenidate has been prescribed for a 7-year-old child with attention deficit-hyperactivity disorder (ADHD) and is to be taken with meals. What rationale does the nurse provide for the parents about the timing of medication administration? 1. Ritalin depresses the appetite. 2. This will ensure proper absorption. 3. It is an oral mucous membrane irritant. 4. Children tend to forget to take it before meals.
1. Ritalin depresses the appetite. A side effect of methylphenidate is anorexia; it should be given during or immediately after breakfast. The absorption rate is not affected by the timing of when it is given. Oral mucous membrane irritation is not a side effect of methylphenidate. In a child of this age the parents are responsible for administering medications.
A 12-year-old child with Down syndrome is admitted to the hospital for intravenous antibiotics for pneumonia. Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply. 1. Saddle nose 2. Thin fingers 3. Inner epicanthic folds 4. Hypertonic musculature 5. Transverse palmar crease
1. Saddle nose 3. Inner epicanthic folds 5. Transverse palmar crease Children with Down syndrome have a broad nose with a depressed bridge (saddle nose), as well as inner epicanthic folds and oblique palpebral fissures; they also have speckling of the iris (Brushfield spots). Children with Down syndrome have a transverse palmar crease (simian crease) formed by fusion of the proximal and distal palmar creases. These children also have broad, short, stubby hands and feet. Children with Down syndrome have hypotonic, not hypertonic, musculature.
The nurse is providing care to an infant diagnosed with Down syndrome. Which parental statement related to the infant's growth indicates the need for further education? 1. "My baby will have growth deficiencies during infancy." 2. "My child will have accelerated growth during adolescence." 3. "My child will most likely be overweight by 3 years of age." 4. "My baby will have reduced growth in both height and weight."
2. "My child will have accelerated growth during adolescence." Children diagnosed with Down syndrome will often have growth deficiencies. These deficiencies are most pronounced during adolescence and infancy. Because weight gain is more rapid than growth in stature, many children with Down syndrome are overweight by 3 years of age. Overall reduced growth is noted for both height and weight.
A parent objects to the child's getting vaccinated because she believes that vaccinations can cause autism. However, a nurse gives the child the vaccination injection against the wishes of the mother. What legal charge may be brought against the nurse? 1. Assault 2. Battery 3. Invasion of privacy 4. False imprisonment
2. Battery Battery is any intentional touching without consent. Because the nurse has administered the injection without obtaining consent, he or she is liable for a charge of battery. Assault is any action that places a person in apprehension of harmful or offensive contact without consent. Invasion of privacy involves unwanted intrusion into the private affairs of a client. False imprisonment means unjustified restraint of a person without a legal warrant.
A 6-year-old child with autism is nonverbal and makes limited eye contact. What should the nurse do initially to promote social interaction? 1. Encourage the child to sing songs with the nurse. 2. Engage in parallel play while sitting next to the child. 3. Provide opportunities for the child to play with other children. 4. Use therapeutic holding when the child does not respond to verbal interactions.
2. Engage in parallel play while sitting next to the child. Entering the child's world in a nonthreatening way helps promote trust and eventual interaction with the nurse. Using therapeutic holding may be necessary when a child initiates self-mutilating behaviors. Singing songs with the child participating or providing opportunities for the child to play with other children is unrealistic at this time; playing with others is a long-term objective.
Which interventions does the nurse implement to empower a family who has a child with Down syndrome? Select all that apply. 1. Ask the family to engage in spiritual activities. 2. Help the family recognize the possible stressors. 3. Encourage the use of problem-solving strategies. 4. Encourage more out-of-home activities for the parents. 5. Refer the family to support groups and Internet resources.
2. Help the family recognize the possible stressors. 3. Encourage the use of problem-solving strategies. 5. Refer the family to support groups and Internet resources. The nurse understands that the family experiences multiple stressors and helps the family recognize those stressors. The nurse encourages the family to use effective problem-solving skills that convey support and care and have a calming influence on the child. The nurse also identifies proper support groups for the family to relieve stress. The use of Internet resources will help the family understand more about the child's disorder. Asking the family to engage in spiritual activities is not appropriate, because spirituality is a personal lifestyle choice. The nurse encourages the parents to spend more time at home to provide care for the child, as opposed to engaging in more out-of-home activities.
A second-grade teacher discusses the behavior of one of the students with the school nurse. The school nurse suspects that the child has attention deficit-hyperactivity disorder (ADHD). Which finding often is associated with ADHD? 1. Hostility 2. Impulsivity 3. Excellent testing ability 4. Positive peer relationships
2. Impulsivity Criteria for diagnosis of ADHD include maladaptive behavior lasting at least 6 months and characterized by inattention, impulsiveness, and overactivity. Impulsivity often results in unsafe behaviors. Hostility is more characteristic of oppositional defiant disorder. Excellent testing ability is unexpected in ADHD. Inattention to detail, careless mistakes, and difficulty organizing work, which are associated with ADHD, hinder the affected child's test-taking ability. Peer relationships are usually strained and of short duration.
Medication is prescribed for a 7-year-old child with attention deficit-hyperactivity disorder (ADHD). What information should the school nurse emphasize when discussing this child's treatment with the parents? 1. Tutoring their child in the subjects that are troublesome 2. Monitoring the effects of the drug on their child's behavior 3. Explaining to their child that the behavior can be controlled if desired 4. Avoiding imposing too many rules because these will frustrate the child
2. Monitoring the effects of the drug on their child's behavior By monitoring and reporting changes in the child's behavior, the healthcare provider can determine the effectiveness of the medication and the optimal dosage. Parents should not be encouraged to tutor their children because there may be too much emotional interaction. This child's behavior is not deliberate or easily controllable; this type of statement may lead to diminished self-esteem in the child if control does not occur. Children, especially children with ADHD, need more structure than do adults.
When assessing a toddler with autism, what characteristic findings or behaviors should the nurse expect? Select all that apply. 1. The desire to hug the nurse 2. Sad, blank facial expression 3. Laughing when pulse is taken 4. Inability to maintain eye contact 5. Inappropriate smiling and flat emotions
2. Sad, blank facial expression 4. Inability to maintain eye contact The inability to maintain eye contact reflects withdrawal. Children with autism are unable to or find it difficult to form meaningful human relationships. Therefore emotion is rarely expressed (for example, through hugging). The facial expression is blank; sadness is a response to the external world from which the child has withdrawn. The child with autism tends to overrespond to stimuli in the environment. Many children with autism rarely, if ever, smile or laugh.
A 37-year-old woman agrees to have a prenatal test done in order to diagnose fetal defects. There is a history of Down syndrome in her family. Which invasive prenatal test provides the earliest diagnosis and rapid test results? 1. Nonstress test 2. Amniocentesis 3. Chorionic villus sampling 4. Percutaneous umbilical blood sampling
3. Chorionic villus sampling Chorionic villus sampling may be performed between 10 and 12 weeks' gestation. The nonstress test, which is not invasive, is a technique used for antepartum evaluation of the fetus; it does not reveal fetal defects. Amniocentesis may be performed after 14 weeks' gestation, when sufficient amniotic fluid is available. Direct access to the fetal circulation with percutaneous umbilical blood sampling may be performed during the second and third trimesters.
A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should prompt the nurse to perform further assessment? 1. Flat occiput 2. Small, low-set ears 3. Circumoral cyanosis 4. Protruding furrowed tongue
3. Circumoral cyanosis Circumoral cyanosis is not a specific characteristic of Down syndrome. It is a clinical finding associated with congenital heart disease, which these infants may have as a concurrent problem. A flat occiput and a broad nose with a depressed bridge (saddle nose) are features of children with Down syndrome. Small, misshapen, low-set ears are also a clinical manifestation of Down syndrome. Children with Down syndrome often keep their mouths open, with their tongues protruding; the surface of the tongue is often wrinkled.
The mother of an infant with Down syndrome asks the nurse what causes the disorder. Before responding, the nurse recalls that the genetic factor of Down syndrome results from what? 1. An intrauterine infection 2. An X-linked genetic disorder 3. Extra chromosomal material 4. An autosomal recessive gene
3. Extra chromosomal material Down syndrome (trisomy 21) results from extra chromosomal material on chromosome 21. Down syndrome does not result from a maternal infection. Down syndrome is not related to an X-linked or Y-linked gene. An autosomal recessive gene is not the cause of Down syndrome, although translocation of chromosomes 15 and 21 or 22 is a genetic aberration found in some children with Down syndrome.
A 10-year-old child in whom autism was diagnosed at the age of 3 years attends a school for developmentally disabled children and lives with parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. What is the priority nursing goal for this child? 1. Controlling repetitive behaviors 2. Being able to feed independently 3. Remaining safe from self-inflicted injury 4. Developing control of urinary elimination
3. Remaining safe from self-inflicted injury The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Children who need help with toileting are not necessarily incontinent, and it is not the priority.
A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions? 1. Hold the child. 2. Place the child in time-out. 3. Use another activity to distract the child. 4. Determine the reason for the child's behavior.
3. Use another activity to distract the child. Providing a constructive distraction will help redirect the autistic child's behavior. Physical contact provokes anxiety for the autistic child. A time-out is punitive and is not constructive. The reason for this repetitive behavior is unknown.
What is a possible outcome criterion for a client diagnosed with anxiety disorder? A. Client demonstrates effective coping strategies. B. Client reports reduced hallucinations. C. Client reports feelings of tension and fatigue. D. Client demonstrates persistent avoidance behaviors.
A. Client demonstrates effective coping strategies. Option A is the only desirable outcome listed for this diagnosis.
A client elects to have her pregnancy terminated after finding out at 16 weeks' gestation that she is carrying a fetus with Down syndrome. What should the nurse conclude about an abortion at this stage of the pregnancy? 1. The client is exhibiting emotional instability. 2. There is a high risk for a postabortion infection. 3. Contraceptive counseling should be deferred to a later time. 4. An opportunity for the client to express feelings about her decision should be provided.
4. An opportunity for the client to express feelings about her decision should be provided. The client must feel comfortable enough to verbalize her feelings; this will help her complete the grieving process. Concluding that the client is emotionally unstable is a false assumption. Induced abortion is a sterile procedure and should not predispose the client to postoperative infection. Studies show that contraceptive counseling at this time is most important because the client may not return after the abortion.
A nurse is caring for a child with autism. Which intervention is most appropriate in an attempt to promote socialization for this child? 1. Encouraging participation in group activities 2. Providing minimal environmental stimulation 3. Holding and cuddling the child for short periods 4. Imitating and participating in the child's activities
4. Imitating and participating in the child's activities The nurse should begin by attempting to enter the world where the child's attention is currently focused; this is a way of establishing human contact, because the child's usual contacts are inanimate objects. Children with autism have deficits in social development, and relationships are difficult to establish. Autistic children are generally unable to participate in group activities. Providing minimal environmental stimulation will have no effect on the nurse's ability to reach the child; rather, it will reinforce withdrawal. Autistic children generally cannot tolerate body contact and will become rigid when anyone attempts to initiate it.
The nurse manager has delegated tasks to a registered nurse (RN) and unlicensed assistive personnel (UAP) who are paired to provide care for a client with substance abuse. Which hospital care setting uses this model to deliver care to the clients? 1. Hospice care 2. Extended care 3. Long term care 4. Rehabilitative care
4. Rehabilitative care Clients with substance abuse require rehabilitative care. Rehabilitative care uses the partnership model to deliver care to the clients. In this model, the RN and UAP are paired to deliver the care. Hospice care is indicated for end-of-life care in clients. Extended care is provided for older clients. Long-term care is provided for clients with chronic diseases. Hospice care, extended care, and long-term care setting may not require the partnership model to deliver the care to the clients.
A school nurse is formulating a plan of care for a 6-year-old client with attention deficit-hyperactivity disorder (ADHD). What is an appropriate outcome for this child? 1. Developing language skills 2. Avoiding regressive behavior 3. Attending regular classes in school 4. Self-image as an independent person of worth
4. Self-image as an independent person of worth Academic deficits, an inability to function within constraints required in certain settings, and negative peer attitudes often lead to low self-esteem. Children with ADHD are usually quite verbal; children with autism need assistance with language development. When the child receives therapy, regressive behavior is expected, because it is a strategy for reducing anxiety. There is no evidence that this child is on a special education track.
A child diagnosed with attention deficit hyperactivity disorder (ADHD) is reprimanded for taking the nurse's pen without asking first. He responds by shouting, "You don't like me! You won't let me have anything, even a pen!" The nurse is most therapeutic when responding with which statement? A. "I do like you, but I don't like it when you grab my pen." B. "Liking you has nothing to do with whether I will loan you my pen." C. "It sounds as though you are feeling helpless and insecure." D. "You must ask for permission before taking someone else's things."
A. "I do like you, but I don't like it when you grab my pen." This reply shows positive regard for the child while describing the behavior as undesirable. Feedback such as this helps the child feel accepted while making her aware of the effect her behavior has on others. None of the other options provide the necessary degree of positive regard.
A client who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." Which response should the nurse make initially? A. "What things have you done in the past that helped you feel more comfortable?" B. "Let's try to focus on that adorable little granddaughter of yours." C. "Why don't you sit down over there and work on that jigsaw puzzle?" D. "Try not to think about the feelings and sensations you're experiencing."
A. "What things have you done in the past that helped you feel more comfortable?" Because the client is not able to think through the problem and arrive at an action that would lower anxiety, the nurse can assist by asking what has worked in the past. Often what has been helpful in the past can be used again. While distraction may be helpful in some situations, it is not the initial intervention.
A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is the nurse's best response? Select all that apply. A. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." B. "You will likely experience euphoria from the medication." C. "You will likely become dependent on this medication and require other medications to control your pain." D. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal." E. "You will not become physically addicted, but you may develop a physiological addiction."
A. "You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." D. "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal."
The nurse anticipates that the nursing history of a client diagnosed with obsessive compulsive disorder (OCD) will reveal what common assessment data? Select all that apply. A. A history of childhood trauma B. A sibling with the disorder C. A history of sexual abuse D. A previous suicide attempt E. An eating disorder
A. A history of childhood trauma B. A sibling with the disorder C. A history of sexual abuse E. An eating disorder Sexual and physical abuse in childhood or trauma increases the risk of this disorder. Genetics are strongly associated with this disorder. First-degree relatives have twice the risk. OCD tends to occur along with anxiety disorders 76% of the time. Other comorbid conditions include major depressive disorder, bipolar disorder, and eating disorders. Suicide while a concern is not among the most common issues for the client diagnosed with OCD.
The family of a child diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type, is told the evaluation of their child's care will focus on symptom patterns and severity. What is the focus of child's evaluation? Select all that apply. A. Academic performance B. Activities of daily living C. Physical growth D. Social relationships E. Personal perception
A. Academic performance B. Activities of daily living D. Social relationships E. Personal perception For the family and child with ADHD, evaluation will focus on the symptom patterns and severity. For those with ADHD, inattentive type, the focus of evaluation will be academic performance, activities of daily living, social relationships, and personal perception. For those with ADHD, hyperactive-impulsive type or combined type, the focus will be on both academic and behavioral responses.
The nurse is caring for a patient admitted to the hospital with pneumonia that has a history of misusing a variety of sedative-hypnotic drugs. Which manifestations noted by the nurse could be attributed to withdrawal? (Select all that apply.) A. Anxiety B. Tremors C. Seizures D. Delirium E. Drowsiness F. Hypertension
A. Anxiety B. Tremors C. Seizures D. Delirium Withdrawal from sedative-hypnotics can be life threatening. The manifestations and treatment are similar to AWS. Early, the patient may have tremors, anxiety, insomnia, fever, orthostatic hypotension, and disorientation. Later, the patient may experience delirium, seizures, and respiratory and cardiac arrest. Drowsiness would be an effect of taking alprazolam, not withdrawing from it.
A client who is dependent on alcohol tells the nurse, "Alcohol is no problem for me. I can quit anytime I want to." The nurse can assess this statement as indicating which defense mechanism? A. Denial B. Projection C. Rationalization D. Reaction formation
A. Denial Believing that one can control drug use, despite addiction to the substance, is based on denial (escaping unpleasant reality by ignoring its existence). No other options are associated with the client's statement.
What are some primary prevention activities a nurse can perform related to substance abuse? Select all that apply. A. Education to prevent substance abuse B. Focusing on relapse prevention C. Identification of risk factors for abuse D. Medical detoxification E. Referral to a self-help group for stress relief and meditation
A. Education to prevent substance abuse C. Identification of risk factors for abuse E. Referral to a self-help group for stress relief and meditation
A client experiencing a panic attack keeps repeating, "Im dying, I can't breathe.". What action by the nurse should be most therapeutic initially? A. Encouraging the client to take slow, deep breaths B. Verbalizing mild disapproval of the anxious behavior C. Asking the client what he means when he says "I am dying." D. Offering an explanation about why the symptoms are occurring
A. Encouraging the client to take slow, deep breaths Slow diaphragmatic breathing can induce relaxation and reduce symptoms of anxiety. Often the nurse has to tell the client to "breathe with me" and keep the client focused on the task. The slower breathing also reduces the threat of hypercapnia with its attendant symptoms. The client needs help to regain composure and stabilize vital signs; the only option that addresses these issues is the correct option.
Which signs and symptoms are associated with opioid withdrawal? A. Lacrimation, rhinorrhea, dilated pupils, and muscle aches. B. Illusions, disorientation, tachycardia, and tremors. C. Fatigue, lethargy, sleepiness, and convulsions. D. Synesthesia, depersonalization, and hallucinations.
A. Lacrimation, rhinorrhea, dilated pupils, and muscle aches. Symptoms of opioid withdrawal resemble the "flu"; they include runny nose, tearing, diaphoresis, muscle aches, cramps, chills, and fever.
An 8-year-old patient is newly diagnosed with attention deficit hyperactivity disorder (ADHD). It is important that the parents be educated to the fact that symptoms will take which form? (Select all that apply). of, inattention, and impulsivity have to be apparent: Select all that apply. A. Low frustration tolerance B. Poor school performance C. Impulsive behaviors D. Easily intimidated E. Mood swings
A. Low frustration tolerance B. Poor school performance C. Impulsive behaviors E. Mood swings
Selective inattention is first noted when experiencing which level of anxiety? A. Mild B. Moderate C. Severe D. Panic
A. Mild When moderate anxiety is present, the individual's perceptual field is reduced and the client is not able to see the entire picture of events. This is not an initial characteristic of any of the other levels of anxiety.
The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? A. Readiness to change and support system B. Current college performance C. Financial ability D. Availability of immediate family to come to meetings
A. Readiness to change and support system The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual's cultural needs. The other options may be factors but are not the priority factors in planning interventions for the patient as much as the patient's perceived need for change and having others who can lend support outside the hospital.
A young woman reports that although she has no memory of the event, she believes that she was raped. This raises suspicion that she unknowingly ingested what substance? Select all that apply. A. Rohypnol B. Gamma-hydroxybutyrate (GHB) C. ReVia D. Clonidine E. Ayahuasca
A. Rohypnol B. Gamma-hydroxybutyrate (GHB) The drugs most frequently used to facilitate a sexual assault (rape) are flunitrazepam (Rohypnol, "roofies"), a fast-acting benzodiazepine, and gamma-hydroxybutyrate (GHB) and its congeners. These drugs are odorless, tasteless, and colorless; mix easily with drinks; and can render a person unconscious in a matter of minutes. Perpetrators use these drugs because they rapidly produce disinhibition and relaxation of voluntary muscles; they also cause the victim to have lasting anterograde amnesia for events that occur. The description is not associated with any of the other suggested drugs.
The mother of a 3-year-old boy just diagnosed with autism spectrum is tearful and states, "The doctor said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" What response should the nurse provide to the mother's statement? A. "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." B. "Starting him on treatment now gives Taylor a much greater chance for a productive life." C. "If your child starts therapy now, he will be able to stop therapy sooner." D. "If you have questions, it's best to ask the doctor."
B. "Starting him on treatment now gives Taylor a much greater chance for a productive life."
A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? A. Client will return to a predrug level of functioning within 1 week. B. Client will be medically stabilized while in the hospital. C. Client will state within 3 days that they will totally abstain from drugs and alcohol. D. Client will take a leave of absence from college to alleviate stress.
B. Client will be medically stabilized while in the hospital. If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge. The first option is an unrealistic time frame. It is not likely that the patient will make a total commitment to abstinence within this time frame. Although a leave of absence may be an option, the immediate need is to make sure the patient goes through drug and alcohol withdrawal safely.
What can be said about the comorbidity of anxiety disorders? A. Anxiety disorders generally exist alone. B. Depression may occur prior to onset of anxiety. C. Anxiety disorders virtually never coexist with mood disorders. D. Substance abuse disorders rarely coexist with anxiety disorders.
B. Depression may occur prior to onset of anxiety. In many instances, major depression may occur prior to the onset of panic disorder or may occur at the same time. Clinicians and researchers have clearly shown that anxiety disorders frequently co-occur with other psychiatric problems. Major depression often co-occurs and produces a greater impairment with poorer response to treatment.
A patient admitted to the hospital early in the morning for elective surgery asks the nurse if they can go outdoors to have one last cigarette before surgery. What action should the nurse take? A. Tell the patient that smoking is not allowed anywhere on hospital property. B. Notify the surgeon that the patient may need an over-the-counter nicotine replacement agent. C. Inform him that this is an ideal time for him to quit smoking because he cannot smoke right after surgery. D. Contact the anesthesia care provider to ensure that the patient's smoking history is noted as a risk factor for surgery.
B. Notify the surgeon that the patient may need an over-the-counter nicotine replacement agent. When smokers are hospitalized, it is important to acknowledge their addiction and encourage them to stop tobacco use. In a stressful time such as surgery, nicotine replacement agents are helpful to control withdrawal cravings and should be used with any support and assistance needed. Although smoking is a risk for postoperative complications, the anesthesia care provider would assess and manage the effects of tobacco use. Just telling the patient that smoking is not allowed is not therapeutic.
A client prescribed a monamine oxidase inhibitor (MOA) has a pass to go out to lunch. Given a choice of the following entrees, the client can safely eat A. avocado salad plate. B. fruit and cottage cheese plate. C. kielbasa and sauerkraut. D. liver and onion sandwich.
B. fruit and cottage cheese plate. Fruit and cottage cheese do not contain tyramine. Avocados, fermented food such as sauerkraut, processed meat, and organ meat, contain tyramine. Monoamine oxidase inhibitors inhibit the breakdown of tyramine, which can lead to high blood pressure, a hypertensive crisis, and eventually a cerebrovascular accident. This information makes the other options incorrect.
The primary goal in caring for the child with cognitive impairment is to: A. encourage play. B. promote optimum development. C. help families adjust to future care. D. develop vocational skills.
B. promote optimum development. Provide parents guidance for the selection of developmentally appropriate activities. A comprehensive approach is desirable to establish acceptable social behavior and feelings of self-worth in the child. This is an ongoing process that changes as the child meets developmental milestones. These skills will be addressed as the child's capabilities are developing.
A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? A. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." B. "I will not take any over-the-counter medication while on the fluoxetine." C. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." D. "I will report increased thirst and urination to my provider."
C. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." This describes symptoms of serotonin syndrome, a life-threatening complication of SRRI medication. The other options are incorrect because the patient should be wearing sunscreen to avoid sunburn, may take over-the-counter medications if sanctioned by the provider, and would not have been educated to report increased thirst and urination as a side effect of fluoxetine.
A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? A. "I will call your care provider. Perhaps you need a different medication." B. "Don't worry. We can try taking it at a different time of day to help it work better." C. "It usually takes a few weeks for you to notice improvement from this medication." D. "Your life is much better now. You will feel better soon."
C. "It usually takes a few weeks for you to notice improvement from this medication."
What is an appropriate long-term client-centered goal/outcome for a recovering substance abuser. A. Ability to discuss the addiction with significant others. B. State an intention to stop using illegal substances. C. Abstain from the use of mood-altering substances. D. Substitute a less addicting drug for the present drug.
C. Abstain from the use of mood-altering substances. Abstinence is a highly desirable long-term goal/outcome. It is a better outcome than short-term goal because lapses are common in the short term. The remaining options would be considered short-term goals.
Panic attacks in Latin American individuals often involve demonstration of which behavior? A. Repetitive involuntary actions B. Blushing C. Fear of dying D. Offensive verbalizations
C. Fear of dying Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness or tingling, as well as fear of dying. This information directs you to the correct options.
The plan of care for a client who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? A. Having the client repeatedly touch "dirty" objects B. Not allowing the client to seek reassurance from staff C. Not allowing the client to wash hands after touching a "dirty" object D. Telling the client that he or she must relax whenever tension mounts
C. Not allowing the client to wash hands after touching a "dirty" object Response prevention is a technique by which the client is prevented from engaging in the compulsive ritual. A form of behavior therapy, response prevention is never undertaken without physician approval. None of the other options reflect accurate information regarding this form of therapy.
The patient tells the nurse that he has used cannabis regularly for the past 20 years. What should the nurse expect to find in the history and physical assessment? (Select all that apply.) A. Gastric ulcers B. Violent behavior C. Productive cough D. Memory impairment E. Crackles in the lungs F. Coronary artery disease
C. Productive cough D. Memory impairment E. Crackles in the lungs Smoking cannabis presents similar health risks to smoking tobacco. The risk for bronchitis increases with the deeper inhalation and longer holding of the smoke when smoking cannabis compared with cigarette smoking. Regular cannabis use impairs the ability to learn and remember. Gastric ulcers are more likely to be occur with regular use of opioids. Violent behavior is more likely with amphetamines. Coronary artery disease would be increased with the regular use of nicotine.
In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. B. there are no physical symptoms associated with fetal alcohol syndrome (FAS) so it may be harder to diagnose. C. alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. D. both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
C. alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. The pattern of growth restriction persists after birth. There are classic physical symptoms associated with the clinical diagnosis of fetal alcohol syndrome (FAS), which are easily recognizable. Some learning problems do not become evident until the child is in school. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.
CIWA-Ar
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised 9 item symptom rating scale, max score 67; <10 does not warrant intervention; score range for each category 0-7
The genetic testing of a child with Down syndrome (DS) showed that it was caused by translocation. The parents ask about further genetic testing. The nurse's BEST response for the parents is: A. "No further genetic testing is indicated." B. "The child should be retested to confirm diagnosis of DS." C. "The mother should be tested if she is over age 35." D. "The parents can be tested themselves because the child's condition might be hereditary."
D. "The parents can be tested themselves because the child's condition might be hereditary." The child does not require further genetic testing, but parents and siblings do. Retesting is not necessary because the diagnosis has been validated with chromosome testing. This type of chromosome abnormality occurs in children of parents of all ages. The parents and any siblings should be tested. Down syndrome resulting from a translocation may be inherited. This type of chromosome abnormality presents issues for future pregnancies.
The nurse caring for a client experiencing a panic attack anticipates that the psychiatrist would order a stat dose of which classification of medications? A. Standard antipsychotic medication. B. Tricyclic antidepressant medication. C. Anticholinergic medication. D. A short-acting benzodiazepine medication.
D. A short-acting benzodiazepine medication. A short-acting benzodiazepine is the only type of medication listed that would lessen the client's symptoms of anxiety within a few minutes. Anticholinergics do not lower anxiety; tricyclic antidepressants have very little antianxiety effect and have a slow onset of action; and a standard antipsychotic medication will lower anxiety but has a slower onset of action and the potential for more side effects.
A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? A. Amitriptyline is very expensive, so the patient may have to buy fewer at a time. B. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness. C. The health care provider wants to see whether any side effects occur within the first week of administration. D. Amitriptyline is lethal in overdose.
D. Amitriptyline is lethal in overdose. Amitriptyline is a tricyclic antidepressant (TCA); these drugs are known to be lethal in smaller doses than other antidepressants. Because the patient had a plan of overdose, the best course of action is to give a small prescription requiring her to visit her provider's office more often for monitoring of suicidal ideation and plan. Tricyclics are not known to be expensive. Antidepressant therapy usually takes several weeks to produce full results, so the patient would not be evaluated after only 1 week. Side effects are always a consideration but not the most important consideration with TCAs.
The nurse is providing teaching to a preoperative patient just before surgery. The patient is becoming more and more anxious and begins to report dizziness and heart pounding. The patient also appears confused and is trembling noticeably. Considering the scenario, what decision should the nurse make? A. To reinforce the preoperative teaching by restating it slowly. B. Have the patient read the teaching materials instead of providing verbal instruction. C. Have a family member read the preoperative materials to the patient. D. Do not attempt any further teaching at this time.
D. Do not attempt any further teaching at this time.
Benzodiazepines are useful for treating alcohol withdrawal because they are associated with which action? A. Blocking cortisol secretion B. Increasing dopamine release C. Decreasing serotonin availability D. Exerting a calming effect
D. Exerting a calming effect Benzodiazepines act by binding to α-aminobutyric acid receptor sites, producing a calming effect. Benzodiazepines are not associated with any of the other suggested actions.
A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. The nurse should provide the client with what information regarding this practice? A. Agreeing that this will help the client to remember the medications. B. Caution the client to drink several glasses of water daily. C. Suggest that the client also use a sun lamp daily. D. Explain the high possibility of an adverse reaction.
D. Explain the high possibility of an adverse reaction. Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants. None of the other options are relevant to the situation.
What is the major distinction between fear and anxiety? A. Fear is a universal experience; anxiety is neurotic. B. Fear enables constructive action; anxiety is dysfunctional. C. Fear is a psychological experience; anxiety is a physiological experience. D. Fear is a response to a specific danger; anxiety is a response to an unknown danger.
D. Fear is a response to a specific danger; anxiety is a response to an unknown danger. Fear is a response to an objective danger; anxiety is a response to a subjective danger. This information helps identify the correct option.
A symptom commonly associated with panic attacks? A. Obsessions B. Apathy C. Fever D. Fear of impending doom
D. Fear of impending doom The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur. None of the other symptoms are associated with a panic attack.
The school nurse knows that which attribute is characteristic of the psychosocial development of school-age children? A. A developing sense of initiative is very important. B. Peer approval is not yet a motivating power. C. Motivation comes from extrinsic rather than intrinsic sources. D. Feelings of inferiority or lack of worth can be derived from children themselves or from the environment.
D. Feelings of inferiority or lack of worth can be derived from children themselves or from the environment.
A patient is receiving lorazepam to prevent the occurrence of delirium tremens. Which manifestation would the nurse recognize as indicative of an overdose of this medication? A. Bradycardia B. Hyperreflexia C. Warm, flushed skin D. Shallow respirations
D. Shallow respirations Clinical manifestations of benzodiazepine overdose include shallow respirations, hypotension; weak, rapid pulse; slow reflexes; impaired motor function; coma; and possible death.
The term tolerance, as it relates to substance abuse, refers to which situation? A. The use of a substance beyond acceptable societal norms B. The additive effects achieved by taking two drugs with similar actions C. The signs and symptoms that occur when an addictive substance is withheld D. The need to take larger amounts of a substance to achieve the same effects
D. The need to take larger amounts of a substance to achieve the same effects With regard to substance abuse, tolerance is defined as the need to take higher and higher doses of a drug to achieve the desired effect. This is the only option that describes the effects of tolerance.
7. In pediatric mental health there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select all that apply. a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit c. Markedly increased funding d. Premature termination of services
a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit d. Premature termination of services
1. A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea
a. Intense nausea b. Diaphoresis d. Confusion e. Dyspnea
5. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply. a. Limited language skills b. Level of cognitive development c. Level of emotional development d. Parental denial that a problem exists e. Severity of the typical mental illnesses observed in young children
a. Limited language skills b. Level of cognitive development c. Level of emotional development
6. Lester and Eileen have always enjoyed gambling. Lately, Eileen has discovered that their savings account is down by $50,000. Eileen insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states: a. "I understand that I am a bad person for depleting our savings." b. "Gambling activates the reward pathways in my brain." c. "Gambling is the only thing that makes me feel alive." d. "We have always enjoyed gaming. I do not know why Eileen is so upset."
b. "Gambling activates the reward pathways in my brain."
3. Cognitive-behavioral therapy is going well when a 12-year- old patient in therapy reports to the nurse practitioner: a. "I was so mad I wanted to hit my mother." b. "I thought that everyone at school hated me. That's not true. Most people like me and I have a friend named Todd." c. "I forgot that you told me to breathe when I become angry." d. "I scream as loud as I can when the train goes by the house."
b. "I thought that everyone at school hated me. That's not true. Most people like me and I have a friend named Todd."
3. The nursing diagnosis ineffective denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply. a. Reports inability to cope b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern
b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern
9. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that: a. Time-out is an important part of April's baseline discipline. b. Time-out is no longer an effective therapeutic measure. c. April enjoys time-out, and acts out to get some alone time. d. Time-out will need to be replaced with seclusion and restraint.
b. Time-out is no longer an effective therapeutic measure.
10. Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. He is cachexic, has multiple scabs on his arms and legs, and has lower extremity edema. An appropriate nursing diagnosis for Donald along with an expected outcome is: a. Risk for injury/Remains free from injury b. Ineffective denial/Accepts responsibility for behavior c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs d. Risk for suicide/Expresses feelings, plans for the future
c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs
interprofessional care/interventions for alcohol withdrawal delirium
• Continued use of benzodiazepines • Valproic acid or gabapentin to treat seizures • Antipsychotic agents (haloperidol [Haldol]) • Chlordiazepoxide if psychosis persists after benzodiazepine administration
manifestations of alcohol withdrawal delirium
• Disorientation • Visual, tactile, or auditory hallucinations • Seizures
A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the primary health care provider (PHCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.
1. Call the nursing supervisor.
A male client with the dual diagnosis of major depression and polysubstance abuse has been attending group therapy. One day the client tells the nurse, "The things they talk about in group don't really pertain to me." What is the most therapeutic response by the nurse? 1. Confronting the client with realistic feedback 2. Identifying the client's stress-coping tolerance 3. Informing the client that he needs to get more involved 4. Asking the client what therapy he thinks would be more helpful
1. Confronting the client with realistic feedback The client is using denial to separate from group members and needs realistic feedback to prevent withdrawal. Identifying the client's stress-coping tolerance will not help the client become involved with the group. Informing the client that he needs to get more involved is inadequate; the client first needs to recognize that the problems being discussed are applicable. The client is avoiding treatment. Asking about therapy preferences is not helpful.
What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation? 1. Electroconvulsive therapy 2. Short-term psychoanalysis 3. Nondirective psychotherapy 4. High doses of anxiolytic drugs
1. Electroconvulsive therapy Electroconvulsive therapy, which interrupts established patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable depression that does not respond to antidepressant medication. The client's depressed mood limits participation in psychotherapy; feelings precipitated by therapy may lead to suicidal acting out. Psychotherapy is directed toward helping the person learn new coping mechanisms and better ways of coping with problems; the depressed client needs direction to accomplish this. Antianxiety medications are usually not prescribed for clients with depression.`
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is the best response by the nurse? 1. "It must be frustrating to deal with your child's behavior." 2. "Have you considered any alternatives to using medication?" 3. "Perhaps you're looking for an easy solution to the problem." 4. "Let me teach you about the side effects of medications used for ADHD."
1. "It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.
After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? 1. Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min 2. Blood pressure of 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths/min 3. Blood pressure of 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths/min 4. Blood pressure of 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths/min
1. Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid.
A client with depression was prescribed fluoxetine. After two days, the client arrives at the hospital and reports restlessness, confusion, and poor concentration. Upon assessment, the nurse finds an elevated body temperature. Which intervention by the healthcare provider would be beneficial to the client? 1. Withdrawing the drug 2. Administering isocarboxazid 3. Reducing the dose of the drug 4. Informing the client that these are expected side effects
1. Withdrawing the drug Restlessness, confusion, poor concentration, and fever are symptoms of serotonin syndrome. The only treatment for serotonin syndrome is discontinuation of the drug. Isocarboxazid is a monoamine oxidase inhibitor that should not be used in a client with serotonin syndrome because it may lead to life-threatening conditions. Reducing the drug dosage may not reverse the symptoms completely. Informing the client that these are expected adverse effects is important, but the drug should be discontinued immediately.
Which physical or behavioral signs of substance abuse should a nurse look for in an adolescent? Select all that apply. 1. Worrying about being addicted 2. Showing a high performance in social activities 3. Experiencing an overdose or withdrawal symptoms 4. Worrying about a friend or family member who is addicted 5. Manifesting bizarre behavior or confusion
1. Worrying about being addicted 3. Experiencing an overdose or withdrawal symptoms 5. Manifesting bizarre behavior or confusion Worrying of being addicted, experiencing overdose or withdrawal symptoms, and manifesting bizarre behavior may be earliest signs of substance abuse. Showing high performance in social activities and worry about a friend or family member's substance abuse are not with a manifestation of substance abuse.
A client diagnosed with depression is prescribed phenelzine. Which foods consumed along with this drug would cause a hypertensive crisis? Select all that apply. 1. Yogurt 2. Soy sauce 3. Cream cheese 4. Soybean paste 5. Over-ripened bananas
2. Soy sauce 4. Soybean paste 5. Over-ripened bananas Monoamine oxidase inhibitors (MAOIs) may cause hypertensive crisis if the client consumes foods rich in tyramine. Bananas, soy sauce, and soybean paste contain high amounts of tyramine. Yogurt and cream cheese do not contain tyramine.
A client is admitted to the psychiatric service with a diagnosis of severe depression. When approached by the nurse, the client says, "You know I'm a sorry, lazy person. I don't deserve a job. I'm just stupid and no good." What does the nurse conclude that the client is experiencing? 1. Nihilistic delusions 2. Delusions of persecution 3. Feelings of self-deprecation 4. Experiences of depersonalization
3. Feelings of self-deprecation The client's statements are self-derogatory and reveal low self-esteem. There is no evidence of feelings about nonexistence. There is no evidence that the client feels controlled or manipulated by others. There is no evidence that the client has a feeling of unreality or of alienation from the self.
The nurse suspects serotonin syndrome in a client prescribed second-generation antidepressants for depression. Which assessment findings observed by the nurse would be beneficial in diagnosing the severity of the syndrome? Select all that apply. 1. Delirium 2. Hyperreflexia 3. Hyperthermia 4. Muscle spasms 5. Rhabdomyolysis
3. Hyperthermia 5. Rhabdomyolysis Serotonin syndrome is a potentially hazardous adverse effect of second-generation antidepressants that are used to treat depression. Hyperthermia and rhabdomyolysis are symptoms observed in severe cases of serotonin syndrome. Delirium, hyperreflexia, and muscle spasms are common symptoms of this syndrome.
A lactating woman takes fluoxetine to treat depression. Her newborn developed tremors, seizures, and fever. Which drug-induced physiologic alterations may be responsible for the central nervous system effects of the drug on the neonate? 1. Increase in fat content 2. Increase in protein binding 3. Immature blood-brain barrier 4. Delayed first stooling
3. Immature blood-brain barrier Many drugs are able to enter the neonate's brain due to the immature blood-brain barrier causing central nervous system effects. Neonates have a low fat content. Protein binding is decreased in neonates because the liver is immature and produces fewer proteins. First pass elimination is decreased in neonates due to the liver's immaturity.
A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? 1. Heroin 2. Cocaine 3. Nicotine 4. Marijuana
3. Nicotine Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.
A nurse is counseling a client who is experiencing substance abuse delirium. What communication strategies should be used by the nurse when working with this client? 1. Encouraging the client to practice self-control 2. Using humor when communicating with the client 3. Offering an introduction to the client at each meeting 4. Approaching the client from the side rather than the front
3. Offering an introduction to the client at each meeting Clients with delirium have short-term memory loss; therefore it is necessary to reinforce information. A client experiencing delirium is unable to participate in a discussion about self-control. Humor is inappropriate and may cause the client to feel uncomfortable. Approaching the client from the side rather than the front may initiate a startle response, causing the client to become fearful.
It is determined that a staff nurse has a drug abuse problem. What approach to the staff nurse's addiction should be taken as an initial intervention? 1. Counseled by the staff psychiatrist 2. Dismissed from the job immediately 3. Referred to the employee assistance program 4. Forced to promise to abstain from drugs in the future
3. Referred to the employee assistance program Referral to the employee assistance program is a nonpunitive approach that attempts to help the nurse as an individual and as a professional. Counseling by the staff psychiatrist may be necessary for long-term therapy but is not the initial approach. Dismissing the nurse from the job immediately is a punitive nontherapeutic response that offers no chance of rehabilitation. The client has an addiction problem; promises will not keep the client from abusing drugs.
Naltrexone is used to treat clients with substance abuse problems. In which situation does the nurse anticipate that naltrexone will be administered? 1. To treat opioid overdose 2. To block the systemic effects of cocaine 3. To decrease the recovering alcoholic's desire to drink alcohol 4. To prevent severe withdrawal symptoms from antianxiety agents
3. To decrease the recovering alcoholic's desire to drink alcohol Naltrexone is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone, not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. Naltrexone is an opioid antagonist. It is not used for antianxiety agent withdrawal.
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? 1. Are unaware that the ritual serves no purpose 2. Can alter the ritual depending on the situation 3. Should be prevented from performing the ritual 4. Do not want to repeat the ritual but feel compelled to do so
4. Do not want to repeat the ritual but feel compelled to do so The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.
A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? 1. "Okay; we don't have to talk about it." 2. "Why don't you want to talk about it?" 3. "What were you doing yesterday when you first noticed the feeling?" 4. "I understand, but don't be concerned; that feeling probably won't come back."
3. "What were you doing yesterday when you first noticed the feeling?" The response "What were you doing yesterday when you first noticed the feeling?" helps the client focus on a situation that has precipitated frightening feelings. Saying "Okay; we don't have to talk about it" avoids an opportunity for the nurse to help the client explore feelings. The client may not be able to answer the question "Why don't you want to talk about it?" The focus should be on feelings. The response "I understand, but don't be concerned; that feeling probably won't come back" is false reassurance; the nurse cannot guarantee that the feelings will not come back.
A primary healthcare provider recently diagnosed attention deficit-hyperactivity disorder (ADHD) in a pediatric client. When working with the family of this child, what should the nurse initially assess about the parents? 1. History of the disorder 2. Relationship with each other 3. Attitudes about the diagnosis 4. Understanding of the treatment regimen
3. Attitudes about the diagnosis The parents' attitudes about the diagnosis are the priority, because they will influence the direction of the plan of care and indicate whether they are ready to learn and participate in the plan of care. Although the parents' relationship with each other and their understanding of the treatment regimen will be assessed eventually, neither is the priority at this time.
A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client? 1. Confronting the client about substance abuse 2. Avoiding calling attention to the client's drug abuse 3. Determining the amount and time of last use of the substance 4. Realizing that this client will need more pain medication than a nonabuser
3. Determining the amount and time of last use of the substance Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms on the time and amount of last use. Confronting the client is not the nurse's responsibility at this time. The client must be helped to recognize that a problem with drugs exists, but this is not the priority. Because of cross-tolerance the client may need larger doses of analgesia for pain relief than a nonabuser would, but this is not the priority.
A nurse is using cognitive therapy to help a client who experiences panic attacks. What is the goal of this therapy? 1. Preventing future panic attacks 2. Helping the client hide the panic attacks 3. Stopping the panic attacks once they begin 4. Decreasing the fear of having panic attacks
4. Decreasing the fear of having panic attacks It is the fear of having an attack as much as the panic attack itself that is debilitating. Once the client's fear of future attacks is diminished, the number of attacks usually decreases as well. Prevention of future attacks is desirable but not always possible. Hiding the attacks is not a goal of therapy. Assisting the client to cope would be more helpful. It usually is impossible to stop a panic attack once it starts.
A team approach is used to help a 6-year-old boy with attention deficit-hyperactivity disorder (ADHD). What behaviors indicate that the interventions have been effective? Select all that apply. 1. Is not inhibited by rules or routines 2. Has fun playing with toys by himself 3. Is no longer enuretic during the night 4. Has an increased attention span in school 5. Is able to wait his turn when in line with others
4. Has an increased attention span in school 5. Is able to wait his turn when in line with others One characteristic of children with ADHD is the inability to remain focused on any activity; an increased attention span in school indicates that the child has improved. Other characteristics of children with ADHD are impulsivity, impatience, and the inability to delay gratification; the ability to wait for one's turn in line indicates that the child has improved. A lack of inhibition by rules or routines indicates that the child has not made sufficient progress and his behavior is still impulsive. Having fun playing with toys by himself indicates that the child has not made progress because children should enjoy playing with peers at this age. A 6-year-old child usually does not experience nocturnal enuresis; there are no data to indicate that the child had enuresis.
An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? 1. Providing psychotherapy to the client 2. Teaching strategies to overcome depression 3. Encouraging the client to walk for 30 minutes 4. Requesting that the physician change the drug
4. Requesting that the physician change the drug Tricyclic antidepressants have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence in older adults. Therefore the priority nursing care for an older client who is prescribed a tricyclic antidepressant is to request that the physician change the drug. Providing psychotherapy is an alternate treatment, which is of medium priority. Teaching strategies to overcome depression is of low priority. Encouraging the client to walk for 30 minutes overcomes the feelings of depression, but it is not the priority.
CIWA-Ar categories
Agitation Anxiety Auditory disturbances Headache Clouding of sensorium Paroxysmal sweats Tactile disturbances Tremor Visual disturbances
Alcoholics Anonymous (AA)
An international nonprofit organization, founded in 1935, consisting of abstinent alcoholics whose purpose is to stay sober and help others recover from the disease of alcoholism through a 12-step program, including group support, shared experiences, and faith in a higher power. (Saunders)
2. The nurse would suspect cocaine toxicity in the patient who is experiencing a. agitation, dysrhythmias, and seizures. b. blurred vision, restlessness, and irritability. c. diarrhea, nausea and vomiting, and confusion. d. slow, shallow respirations; bradycardia; and hypotension.
a. agitation, dysrhythmias, and seizures.
4. While caring for a patient who is experiencing alcohol withdrawal, the nurse should (select all that apply) a. monitor neurologic status on a routine basis. b. provide a quiet, nonstimulating, dimly lit environment. c. pad the side rails and place suction equipment at the bedside. d. orient the patient to environment and person with each contact. e. give antiseizure drugs and sedatives to relieve withdrawal symptoms.
a. monitor neurologic status on a routine basis. c. pad the side rails and place suction equipment at the bedside. d. orient the patient to environment and person with each contact. e. give antiseizure drugs and sedatives to relieve withdrawal symptoms.
5. A patient admitted for scheduled surgery has a positive brief screening test result for an alcohol use disorder. Which initial action is most appropriate? a. Notify the health care provider. b. Complete a detailed alcohol use assessment. c. Initiate a referral to a specialty treatment center. d. Provide patient teaching on postoperative health risks.
b. Complete a detailed alcohol use assessment.
non-nicotine agents
bupropion (Zyban); Contraindicated with history of seizures or eating disorders. Promotes weight loss. First choice for smokers with depression. varenicline (Chantix); If taken concurrently with nicotine replacement therapy, incidence of nausea, headache, vomiting, dizziness, dyspepsia, and fatigue is increased, but nicotine pharmacokinetics not affected.
sympathetic overdrive
increased stimulation of the sympathetic nervous system
Health problems related to snorting drugs
• Nasal sores, septal necrosis or perforation • Chronic sinusitis
Health problems related to opioid use
• Sexual dysfunction • Gastric ulcers • Glomerulonephritis
criteria for substance use disorder
1. Impaired Control • Taking more or for longer than intended • Not quitting use despite multiple times of trying to do so • Spending a great deal of time obtaining, using, or recovering from use • Craving the substance 2. Social Impairment • Missing school, work, or other responsibilities due to use • Continuing use despite problems caused or worsened by use • Giving up or reducing important activities because of use 3. Risky Use • Recurrent use in hazardous situations • Continued use despite causing or worsening problems 4. Pharmacologic Dependence • Physical tolerance to effects of the substance • Presence of withdrawal symptoms when not using or using less
During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1. Lethargy 2. Ambivalence 3. Emotional lability 4. Increased appetite 5. Long periods of sleep
1. Lethargy 2. Ambivalence 3. Emotional lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? SATA. 1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide stimulation in the environment. 5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 5. Provide reality orientation as appropriate.
5 R's (for users unwilling to quit)
1. Relevance: Ask the patient to say why quitting is personally relevant (e.g., health). 2. Risks: Ask the patient to identify his or her potential risks/consequences of tobacco use. 3. Rewards: Ask the patient to relate potential benefits of stopping tobacco use. 4. Roadblocks: Ask patient to identify barriers or impediments to quitting. 5. Repetition: Repeat process every clinic visit.
A new mother is diagnosed with depression. Which antidepressant may be prescribed to this client? 1. Sertraline 2. Fluoxetine 3. Amphetamine 4. Carbamazepine
1. Sertraline Sertraline is considered safe in lactating females. Dosing immediately after breast-feeding can reduce the risk of the drug excreted in the breast milk by the next feeding time. Fluoxetine and amphetamine are not recommended for breast-feeding clients. Carbamazepine is not used to treat depression.
A client with the diagnosis of panic disorder jumps when spoken to, complains of feeling uneasy, and says, "It's as though something bad is going to happen." Which action by the nurse is most therapeutic at this time? 1. Stay with the client to be a calming presence. 2. Encourage the client to communicate with the staff. 3. Allow the client to set the parameters for the interaction. 4. Help the client to understand the cause of the feelings described.
1. Stay with the client to be a calming presence. Fear can be overwhelming; the nurse's presence provides protection from possible danger. The client's anxiety level is interfering with her ability to communicate; anxiety must be reduced first. The client's anxiety level is so high that sufficient emotional energy to set parameters is not available. Helping the client understand the cause of the feelings she describes may increase the client's anxiety at this time.
A breastfeeding mother requires treatment for depression. Which drug would be safe to use if the mother wishes to continue breastfeeding the newborn? 1. Fluoxetine 2. Paroxetine 3. Valproic acid 4. Methotrexate
2. Paroxetine Paroxetine can be safely given during breastfeeding. Fluoxetine can easily enter breast milk; therefore this drug would only be used when other selective serotonin reuptake inhibitors are ineffective. Valproic acid is an antiepileptic drug that can be given safely to breastfeeding women. Methotrexate is an anticancer drug that cannot be given during breastfeeding because it enters the breast milk and can cause adverse effects in the baby.
A child is found to have attention deficit-hyperactivity disorder (ADHD). What strategy should the nurse teach the parents to help them cope with this disorder? 1. Orient the child to reality. 2. Reward appropriate conduct. 3. Suppress feelings of frustration. 4. Use restraints when behavior is out of control.
2. Reward appropriate conduct. External rewards can motivate as well as increase self-esteem in the child with ADHD. Orienting the child to reality is unnecessary, because children with ADHD are alert and oriented. Feelings of frustration should not be suppressed; rather, the child should learn how to cope with these feelings in an acceptable manner. The use of restraints is contraindicated, because they are restrictive and punitive.
A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. What should the nurse suggest to the mother? 1. "Talk with a louder voice." 2. "Shorten the rest of the story." 3. "Encourage your son to pay attention." 4. "Use therapeutic holding for the rest of the story."
2. "Shorten the rest of the story." Shortening the story nonjudgmentally limits the activity while supporting the child's self-esteem; the child with ADHD cannot control his inattention and hyperactivity. The mother should select activities that are more interactive or interesting for the child to engage his attention. The child does not have a hearing problem, and speaking louder will not change the behavior. Inattention and hyperactivity cannot be controlled; encouraging the child to pay attention may precipitate feelings of doubt, shame, or guilt and reinforce low self-esteem. Using therapeutic holding for the rest of the story is unnecessary in this situation; therapeutic holding is used when a child is out of control and at risk for self-harm or violence toward others; it reassures the child that the adult is in control and promotes feelings of security and comfort.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how he thought that he could take drugs without someone finding out. 4. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
2. Ask the client about the amount of drug use and its effect.
Alprazolam is prescribed for a client with the diagnosis of panic disorder. The client refuses to take the medication because of fears of addiction. What should the nurse do initially? 1. Provide the client information about alprazolam. 2. Assess the client's feelings about alprazolam further. 3. Ask the practitioner about changing the client's medication. 4. Have the practitioner speak with the client about the safety of this medication.
2. Assess the client's feelings about alprazolam further. Before deciding how to ease the client's fears of addiction, the nurse must explore the full extent of the client's knowledge and feelings about taking this medication. Information may or may not be helpful; the client's feelings are what must be addressed. Although the nurse may eventually ask the practitioner to consider changing the medication or to speak with the client about its safety, neither is the priority at this time.
A client with anorexia nervosa is a member of a pre-discharge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calories intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge
2. Evidence of the client's disturbed body image
A young adult being treated for substance abuse asks the nurse about methadone. The nurse responds that methadone is useful in the treatment of opioid addiction because it has what characteristic? 1. Is a nonaddictive drug 2. Has an effect of longer duration 3. Does not produce a cumulative effect 4. Carries little risk of psychological dependence
2. Has an effect of longer duration The duration of effect of methadone is 12 to 24 hours, compared with other opioids, which have a 3- to 6-hour duration of effect. It is just as addictive but controls the addiction and keeps the client out of the illicit drug market. Methadone does produce a cumulative effect. Physical as well as psychological dependence is possible, just as with other opioids.
interprofessional care/interventions for alcohol withdrawal syndrome
• Benzodiazepines (e.g., lorazepam, diazepam) to prevent seizures and delirium • Thiamine to prevent Wernicke-Korsakoff syndrome • Multivitamins (e.g., folic acid, B vitamins) • Magnesium sulfate to treat low serum magnesium • IV glucose solution to treat hypoglycemia • β-Blockers (e.g., atenolol) or α2-agonists (e.g., clonidine) to stabilize vital signs • Respiratory support
Health problems related to injecting drugs (substance use)
• Blood clots, phlebitis, skin infections • Hepatitis B and C • HIV/AIDS • Other infections: endocarditis, tuberculosis, pneumonia, meningitis, tetanus, bone and joint infections, lung abscesses
stimulant toxicity assessment findings
Cardiovascular • Palpitations • Tachycardia • ↑ BP • Dysrhythmias • Myocardial ischemia • Chest pain Central Nervous System • Agitation • Euphoria • Insomnia • Combativeness • Seizures • Hallucinations • Confusion • Paranoia • Fever
Health problems related to cocaine use
• Cardiac dysrhythmias, myocardial ischemia and infarction • Seizures, stroke • Psychosis
1. When admitting a patient, the nurse must assess the patient for substance use based on the knowledge that long-term use of addictive substances leads to a. the development of coexisting psychiatric illnesses. b. a higher risk for complications from underlying health problems. c. potentiation of effects of similar drugs taken when the person is drug free. d. increased availability of dopamine, resulting in decreased sleep requirements.
b. a higher risk for complications from underlying health problems.
