Test 1

A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide."

"Bringing up these feelings is a very positive action on your part." gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse.

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide?

"Genetics are associated with suicide risk. Monitoring and support are important."

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship?

"I want to find a way to deal with my anger without becoming violent."

The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in client with posttraumatic stress disorder can be demonstrated by which of the following client self-reports?

"I'm sleeping better and don't have nightmares" MAO inhibitors are used to treat sleep problems, nightmares, and intrusive daytime thoughts in individual with posttraumatic stress disorder

nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?

"Let's consider which problems are very important and which are less important." Helps to develop effective coping skills and reduce overwhelming effects of problems by prioritizing them

An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Which response by the nurse is appropriate?

"What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team."

Which nursing intervention would be most appropriate if a male client develops orthostatic hypotension while taking amitriptyline (Elavil)?

Advising the client to sit up for 1 minute before getting out of bed.

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?

Are you having thoughts of suicide Have to make things clear with what the patient is saying and feeling

When assessing a patient's plan for suicide, what aspect has priority

Availability of means and lethality of method

Dennis has a lithium level of 2.4 mEq/L. The nurse immediately would assess the client for which of the following signs or symptoms?

Blurred vision

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?

Diaphoresis, weakness, and nausea Early signs of lithium toxicity

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse:

Distracts patient by looking at a new fashion magazine

patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?

Do not hit anyone. If you are unable to control yourself, we will help you Limits must be set when patients start to act out of line

Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills.

Do you have access to meds

A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to

Establish rapport with the patient

An adult outpatient diagnosed with major depression has a history of several suicide attempts by over- dose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed?

Fluoxetine (Prozac), a selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations,

Jun approaches the nurse and tells that he hears a voice telling him that he's evil and deserves to die. Which of the following terms describes the client's perception?

Hallucination

Which measure would be considered a form of primary prevention for suicide?

Helping school children learn to manage stress and be resilient

Tristan is on Lithium has suffered from diarrhea and vomiting. What should the nurse in-charge do first:

Hold the next dose and obtain an order for a stat serum lithium level

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is

Hopelessness

person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care?

Hyperactivity; not eating and sleeping

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?

Jumping from a railroad bridge located in a deserted area late at night

Nurse Sarah ensures a therapeutic environment for all the client. Which of the following best describes a therapeutic milieu?

Living, learning, or working environment

During conversation of Nurse John with a client, he observes that the client shift from one topic to the next on a regular basis. Which of the following terms describes this disorder?

Loose association

A health teaching plan for a patient taking lithium should include instructions to

Maintain normal salt and fluids in the diet sodium depletion and dehydration increase the change for development of lithium toxicity

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with

Meals, can help when taking lithium

When a new patient is hospitalized, a nurse takes the patient on a tour, explains rules of the unit, and discusses the daily schedule. The nurse is engaged in

Milieu management Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs.

Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse should plan to

Monitor vital signs, serum electrolyte levels, and acid-base balance

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?

Poor judgement and hyperactivity

Mr. Garcia, an attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. Nurse Beatriz knows that the client's behavior most likely represents the use of which defense mechanism?

Regression

Mike is admitted to a psychiatric unit with a diagnosis of undifferentiated schizophrenia. Which of the following defense mechanisms is probably used by Mike?

Regression Regression, a return to earlier behavior to reduce anxiety, is the basic defense mechanism in schizophrenia

Nurse Myrna develops a counter-transference reaction. This is evidenced by

Revealing personal info to the client

Which change in the brain's biochemical function is most associated with suicidal behavior?

Serotonin deficiency

Rocky has started taking haloperidol (Haldol). Which of the following instructions is most appropriate for Ricky before taking haloperidol?

Should report feelings of restlessness or agitation at once

Cely with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

Sodium Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day.

Mark, with a diagnosis of generalized anxiety disorder wants to stop taking his lorazepam (Ativan). Which of the following important facts should nurse Betty discuss with the client about discontinuing the medication?

Stopping the drug can cause withdrawal symptoms Stopping anti-anxiety drugs such as benzodiazepines can cause the client to have withdrawal symptoms

It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medica- tion. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.

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

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?

The nurse feels unusually happy when the patient's mood begins to lift.

Isabel with a diagnosis of depression is started on imipramine (Tofranil), 75 mg by mouth at bedtime. The nurse should tell the client that:

This medication may initially cause tiredness, which should become less bothersome over time

Katrina, a newly admitted is extremely hostile toward a staff member she has just met, without apparent reason. According to Freudian theory, the nurse should suspect that the client is experiencing which of the following phenomena?

Tranference

Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting

Transference

Nurse Daisy is aware that the following pharmacologic agents are sedative-hypnotic medication is used to induce sleep for a client experiencing a sleep disorder is:

Triazolam (halcion)

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select?

Use distraction techniques

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is:

Within therapeutic limits

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will:

bring hyperactivity under rapid control

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?

carbamazepine (Tegretol)

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." Which response is the nurse demonstrating?

countertransference

Termination of a therapeutic nurse-patient relationship has been successful when the nurse

discusses with the patient changes that happened during the relationship and evaluates outcomes

At what point in the nurse-patient relationship should a nurse plan to first address termination?

during the orientation phase

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical?

heart failure

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification?

lamotrigine (Lamictal) All are anticonvulsants

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate:

rapport and trust with the nurse

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient is- sues will be explored and resolved?

working