CH 35

A patient is prescribed haloperidol. The nurse advises the patient to rise slowly from sitting to a standing position. Which potential side effect of the medication would support this intervention? 1 Akathisia 2 Dry mouth 3 Hypertension 4 Headache

1 Akathisia

Which group of psychotic disorders is characterized by severe and inappropriate emotional responses and prolonged and persistent disturbances of mood and related thought distortions? 1 Mood disorders 2 Anxiety disorders 3 Personality disorders 4 Thought process disorders

1 Mood disorders

Place the four stages of schizophrenia in the correct order.

1. Prodromal Phase 2. Prepsychotic Phase 3. Acute Phase 4. Residual Phase

Which lab value would represent the therapeutic index for lithium maintenance? 1 1 to 1.5 mEq/L 2 0.6 to 1.2 mEq/L 3 2.2 to 2.6 mEq/L 4 3.5 to 5.1 mEq/L

2 0.6 to 1.2 mEq/L

Which signs and symptoms, when exhibited by a patient receiving fluoxetine would indicate the potentially dangerous condition of serotonin syndrome? Select all that apply. 1 Miosis 2 Mydriasis 3 Confusion 4 Bradycardia 5 Tachycardia

2 Mydriasis 3 Confusion 5 Tachycardia

A patient is scheduled for electroconvulsive therapy (ECT) tomorrow morning. She has been pacing the halls and biting her nails for the past 10 minutes. The patient tells the nurse, "I don't know if I can go through with this. I don't remember any side effects to expect!" Which response by the nurse would be best at this time? 1 "Many people get ECT and do fine." 2 "Eat a small meal beforehand to prevent possible nausea." 3 "You might experience short-term amnesia and headache after the procedure." 4 "You will be awake during the procedure; the controlled seizure lasts only 5 seconds."

3 "You might experience short-term amnesia and headache after the procedure."

Which information is important to include when educating patients who start taking venlafaxine? 1 Avoid direct sunlight. 2 Be consistent with salt intake. 3 Weekly blood tests are needed. 4 Full effects will take 2 to 4 weeks.

4 Full effects will take 2 to 4 weeks.

Which nursing intervention should the nurse promote for a child experiencing anxiety about undergoing venepuncture to relieve anxiety? 1 Practice abdominal or deep breathing. 2 Focus on a pleasant image and its details. 3 Use brisk walks, back rubs, and heating pads. 4 Imagine how a hero would tolerate the procedure.

4 Imagine how a hero would tolerate the procedure.

The nurse is caring for a patient with depression. The patient has very little energy and has trouble walking unassisted because of very poor nutrition. Which nursing interventions should the nurse perform to help maintain the patient's normal body weight? Select all that apply. 1 Encourage the patient eat six small meals per day. 2 Monitor the patient's diet and keep a record. 3 Determine the likes and dislikes of the patient. 4 Encourage consumption of coffee in the morning. 5 Discourage consumption of fluids by the patient.

1 Encourage the patient eat six small meals per day. 2 Monitor the patient's diet and keep a record. 3 Determine the likes and dislikes of the patient.

A nurse is admitting a 65-year-old patient whose primary diagnosis is delirium. Which clinical conditions are possible causes of delirium? Select all that apply. 1 Fever 2 Azotemia 3 Liver failure 4 Drug intoxication 5 Congestive heart failure

1 Fever 2 Azotemia 4 Drug intoxication

Which herbal supplement would a nurse suggest adding to a medication regimen to increase cerebral blood flow for a patient diagnosed with Alzheimer's disease? 1 Ginkgo (Ginkgo biloba) 2 Kava (Piper methysticum) 3 Gotu kola (Centella asiatica) 4 St. John's wort (Hypericum perforatum)

1 Ginkgo (Ginkgo biloba)

The nurse is caring for a patient diagnosed with major depression. Which outcomes would the nurse evaluate in the patient after providing effective nursing interventions? Select all that apply. 1 Improvement in sleep patterns 2 Improvement in social interactions 3 Improvement in verbal communication 4 Absence of relocation stress syndrome 5 Reduction in signs of self-directed violence

1 Improvement in sleep patterns 2 Improvement in social interactions 3 Improvement in verbal communication 5 Reduction in signs of self-directed violence

Which nursing interventions should the nurse follow to prevent lithium toxicity in a patient who has been prescribed lithium carbonate? Select all that apply. 1 Monitor lithium levels in the patient. 2 Chart the presence of adverse effects. 3 Monitor changes in the patient's behaviors. 4 Suggest that the patient reduce salt intake. 5 Monitor the patient for symptoms of dehydration.

1 Monitor lithium levels in the patient. 2 Chart the presence of adverse effects. 3 Monitor changes in the patient's behaviors. 5 Monitor the patient for symptoms of dehydration.

A nurse is developing a care plan for a patient with an obsessive-compulsive behavior disorder. Which nursing intervention will most likely increase the patient's anxiety? 1 Permitting the patient's ritualistic acts three times a day 2 Involving the patient in establishing the therapeutic plan 3 Helping the patient understand the nature of the anxiety 4 Providing the patient with a nonjudgmental environment

1 Permitting the patient's ritualistic acts three times a day

The use of toys to assist a child to express feelings is known as which type of treatment? 1 Play therapy 2 Group therapy 3 Behavior therapy 4 Cognitive therapy

1 Play therapy

A nurse is assessing a patient and trying to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. 1 Labile mood 2 Irrelevant speech 3 Hallucinations and illusions 4 Slow deterioration in cognition 5 Fluctuating levels of consciousness

2 Irrelevant speech 3 Hallucinations and illusions 5 Fluctuating levels of consciousness

A patient is being discharged from the psychiatric unit with a prescription for an antipsychotic. Which information should the nurse educate the patient about before discharge? 1 Take medication in the morning. 2 Restrict the intake of salty foods. 3 Undergo monthly laboratory tests. 4 Wear sunscreen and sunglasses when outside.

4 Wear sunscreen and sunglasses when outside.

A patient with delusions, hallucinations, and disordered thinking is diagnosed with schizophrenia. Which therapy in the patient would yield a good response? Select all that apply. 1 Drug therapy 2 Phototherapy 3 Psychotherapy 4 Electroconvulsive therapy (ECT) 5 Play therapy

1 Drug therapy 3 Psychotherapy

The nurse is caring for a patient diagnosed with depression. The patient weighs less than normal because of poor nutrition. Which patient outcome would the nurse evaluate in the patient after providing effective nursing interventions to improve nutrition? 1 The patient eats 50% to 60% of each meal. 2 The patient denies having suicidal thoughts. 3 The patient eats three full meals sitting alone. 4 The patient sleeps at a scheduled time each night.

1 The patient eats 50% to 60% of each meal.

Which precautions should be taken by a nurse for a patient who talks about death, suicide, and withdrawing from family in a hospital environment? Select all that apply. 1 Check the patient every 15 minutes to ensure safety. 2 Allow visitors to leave gifts for the patient in the room. 3 Ensure that the patient swallows the drugs administered. 4 Assign the patient to a room with a closed video monitor. 5 Keep all the articles and furniture according to the patient's wishes.

1 Check the patient every 15 minutes to ensure safety. 3 Ensure that the patient swallows the drugs administered. 4 Assign the patient to a room with a closed video monitor.

The nurse administers haloperidol to a patient with a psychological disorder. For which side effect should the nurse monitor the patient? 1 Hypothermia 2 Renal impairment 3 Cerebral hemorrhage 4 Labile blood pressure

4 Labile blood pressure

A schizophrenic patient is actively hallucinating. He tells the nurse he is hearing the president talk to him. Which response is appropriate for a person hallucinating? 1 "You are not hearing the president." 2 "I am not hearing the president as you are." 3 "I want to hear what the president is saying." 4 "The president would not talk to you if he were here."

2 "I am not hearing the president as you are."

Which are treatment options for posttraumatic stress disorder (PTSD)? Select all that apply. 1 Antipsychotics 2 Antidepressants 3 Cognitive therapy 4 Behavioral therapy 5 Electroconvulsive therapy

2 Antidepressants 3 Cognitive therapy 4 Behavioral therapy

A nurse is assisting a patient with dementia. In addition to reality orientation, which intervention would be important to implement in caring for patients with dementia? 1 Increase sensory stimuli. 2 Give complex instructions. 3 Place bed in lowest position. 4 Document intake and output.

3 Place bed in lowest position.

A nurse monitors a patient with schizophrenia for the side effects of an antipsychotic drug. For which potentially irreversible extrapyramidal side effect should the nurse monitor? 1 Dystonia 2 Akathisia 3 Tardive dyskinesia 4 Pseudoparkinsonism

3 Tardive dyskinesia

Which outcomes does the nurse expect while caring for a patient with a personality disorder? Select all that apply. 1 Reversal of tremors 2 Reduced risk of fall 3 Ventilation of feelings 4 Improved sleeping time 5 Good social interactions

3 Ventilation of feelings 5 Good social interactions

A 16-year-old girl complains of fatigue and hoarseness. Further assessment reveals esophagitis, dental erosion, and palate lacerations. Which diagnosis does the nurse expect to see in the chart based on these findings? 1 Bulimia nervosa 2 Anorexia nervosa 3 Obsessive-compulsive disorder 4 Gastroesophageal reflux disease

1 Bulimia nervosa

The nurse is caring for a patient with bulimia nervosa who reports episodes of overeating. The nurse learns that the patient lacks self-esteem and often feels guilty about overeating. Which nursing interventions can help this patient? Select all that apply. 1 Build a trusting relationship. 2 Measure the baseline vital signs. 3 Monitor the level of consciousness. 4 Help to explore the triggers of overeating. 5 Ask the patient to avoid frequent small meals.

1 Build a trusting relationship. 4 Help to explore the triggers of overeating.

A nurse working on a psychiatric unit knows that there are different therapeutic techniques used. Which component is essential for psychiatric-mental health treatment? 1 The nurse and patient develop a helping-trust relationship. 2 Therapeutic communication is not a necessary part of treatment. 3 The nurse works to resolve mental issues through developing a social relationship with the patient. 4 The information that the patient shares is known by only one individual on the health care team.

1 The nurse and patient develop a helping-trust relationship.

The nurse is caring for a patient diagnosed with depression who avoids interacting with others. Which activity by the patient would the nurse expect after providing effective nursing interventions? Select all that apply. 1 Watches a movie in a theater 2 Sleeps at a scheduled time each night 3 Interacts with other patients and staff 4 Maintains a regular and adequate eating pattern 5 Denies having thoughts of self-directed violence

1 Watches a movie in a theater 3 Interacts with other patients and staff

For which dangerous side effect will the nurse monitor a patient who is taking phenelzine sulfate? 1 Agranulocytosis 2 Hypertensive crisis 3 Extrapyramidal side effects 4 Neuroleptic malignant syndrome

2 Hypertensive crisis

A patient with mania is prescribed lithium carbonate. The nurse advises the patient to take the medication with food. Which outcome does the nurse expect from this intervention? 1 Reduced indigestion 2 Prevention of drowsiness 3 Prevention of kidney damage 4 Decrease in toxic levels of lithium

2 Prevention of drowsiness

A patient is preparing to receive electroconvulsive therapy (ECT). The nurse caring for this patient identifies which nursing concern as the highest priority? 1 Concern with cognition related to confusion 2 Anxiety related to uncertainty of the events of the test 3 Concerns with cognition related to temporary memory loss 4 Lack of knowledge related to lack of information regarding the procedure

2 Anxiety related to uncertainty of the events of the test

A patient who did not respond to a tricyclic antidepressant or a selective serotonin reuptake inhibitor is started on a monoamine oxidase inhibitor (MAOI). Which education should the nurse provide to the patient about MAOIs? 1 Wear sunscreen when outside. 2 Avoid alcohol while taking an MAOI. 3 Take in the morning to avoid insomnia. 4 Serotonin syndrome is a potential side effect.

2 Avoid alcohol while taking an MAOI.

Which nursing interventions should the nurse provide for the patient taking antipsychotic agents? Select all that apply. 1 Instruct the patient not to drive. 2 Check for extrapyramidal effects. 3 Explain the measures to avoid falling. 4 Stop the drug if side effects persist. 5 Suggest that the patient chew gum or candy.

2 Check for extrapyramidal effects. 3 Explain the measures to avoid falling. 5 Suggest that the patient chew gum or candy.

The nurse administers chlorpromazine (Thorazine) to a patient with bipolar disorder. The nurse observes that the patient is unable to sit still. Which changes in the medical plan of care should the nurse expect the health care provider to prescribe? Select all that apply. 1 Stop administering the drug. 2 Decrease the dose of the drug. 3 Follow up with use of benztropine (Cogentin). 4 Administer diphenhydramine (Benadryl). 5 Administer St. John's wort.

2 Decrease the dose of the drug. 3 Follow up with use of benztropine (Cogentin). 4 Administer diphenhydramine (Benadryl)

Which positive behavioral patterns are associated with schizophrenia? Select all that apply. 1 Alogia 2 Delusion 3 Anhedonia 4 Hallucination 5 Concreteness

2 Delusion 4 Hallucination 5 Concreteness

A patient with schizophrenia is admitted to the hospital. Which objectives does the nurse consider in planning the interventions to help the patient? Select all that apply. 1 Improving gait 2 Reducing anxiety 3 Improving social interactions 4 Improving orientation to reality 5 Avoiding interactions during delusions

2 Reducing anxiety 3 Improving social interactions 4 Improving orientation to reality

A patient is taking lithium carbonate to stabilize his mood and behaviors. The nurse knows that the patient is at risk for toxicity, which is commonly encountered with lithium. Which action would increase the risk of toxicity? 1 Continually monitoring lithium levels 2 Restricting fluid intake and sodium in the diet 3 Reporting of nausea and vomiting by the patient 4 Educating regarding the taking of the medication

2 Restricting fluid intake and sodium in the diet

During shift change, the evening nurse reports that a patient displays pseudoparkinsonism. Which assessment findings would the nurse document in the patient record to support this nursing report? 1 Constipation and dry mouth 2 Shuffling gait, tremor, rigidity 3 Bizarre movements of the face and neck 4 Involuntary movements of the tongue and lips

2 Shuffling gait, tremor, rigidity

A patient reports, "I've had a kidney stone for the past 3 months." On diagnosis the health care provider finds the patient's renal function is normal. Which mental disorder is the patient suffering from? 1 Concreteness 2 Somatic delusions 3 Thought withdrawal 4 Thought broadcasting

2 Somatic delusions

A patient diagnosed with depression has been prescribed a tricyclic antidepressant. The nurse educates the patient to expect improvement in the depression within which period of time? 1 4 to 6 days 2 1 to 2 weeks 3 2 to 4 weeks 4 2 to 3 months

3 2 to 4 weeks

Benztropine is often prescribed in conjunction with which type of drug? 1 Anxiolytics 2 Barbiturates 3 Antipsychotics 4 Antidepressants

3 Antipsychotics

The nurse is caring for a patient with schizophrenia who has undergone electroconvulsive therapy (ECT). Which intervention should the nurse perform before administering oral medication post-electroconvulsive therapy? 1 Establish an intravenous line. 2 Assess the patient's vital signs. 3 Assess the patient's gag reflex. 4 Arrange for someone to accompany the patient

3 Assess the patient's gag reflex.

A patient tells a nurse that he must walk around the table four times before he eats any meal; otherwise he will get sick. Which clinical symptom would the nurse document in the patient record? 1 Illusion 2 Obsession 3 Compulsion 4 Hallucination

3 Compulsion

A patient in the manic phase of bipolar disorder is taking lithium. The nurse identifies that the patient's lithium blood level is 1.9 mEq/L. Which action by the nurse would be the most appropriate? 1 Stop the drug until the serum lithium level is 0.4 mEq/L. 2 Continue the usual dose of lithium and note any side effects. 3 Hold the drug and notify the health care provider immediately. 4 Ask the health care provider to increase the dose because of a subtherapeutic range.

3 Hold the drug and notify the health care provider immediately

A nurse is caring for a patient who is being treated with antipsychotic medications. As part of the plan of care, the nurse monitors the patient for dyskinesia. Which symptoms would the nurse assess for with regard to tardive dyskinesia? 1 Migraine headache, hypertension 2 Abnormal respiratory rate and depth 3 Severe flushing, headache, and tremors 4 Involuntary movements of the mouth and tongue

4 Involuntary movements of the mouth and tongue

A patient is prescribed phenelzine sulfate for the treatment of depression. The nurse finds that the patient is using St. John's wort without the advice of the health care provider. Which complication may be expected in the patient due to concomitant use of these drugs? 1 Renal failure 2 Disorientation 3 Phototoxicity 4 Severe hypertension

4 Severe hypertension

A patient is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. Which intervention by the nurse is important to maintain safety of the patient during the 6-week treatment program? 1 Provide tyramine-free meals during the 6 weeks of therapy. 2 Maintain patient's sodium intake prior to each procedure. 3 Avoid patient's exposure to the sun during the 6 weeks of therapy. 4 Stop patient from taking any food by mouth for 8 hours before the procedure.

4 Stop patient from taking any food by mouth for 8 hours before the procedure

A nurse is caring for an older adult who lives in a long-term care facility on the Alzheimer's unit. Every evening at around 5:00 p.m., the resident becomes increasingly agitated and more confused, lasting throughout the evening. Which behaviour would the nurse document in the patient's record? 1 Delirium 2 Dementia 3 Personality disorder 4 Sundowning syndrome

4 Sundowning syndrome

A patient with depression asks the nurse about possible causes of depression. Which response by the nurse would be best? 1 There is no hereditary factor for depression. 2 Most people suffer from depression from time to time. 3 There is an excess of the neurotransmitter norepinephrine. 4 There is a deficiency of the neurotransmitters norepinephrine and serotonin.

4 There is a deficiency of the neurotransmitters norepinephrine and serotonin

A nurse is assessing a patient with schizophrenia who says, "You all know the thoughts I've been having today." Which type of delusion would the nurse document the patient as having? 1 Somatic delusions 2 Ideas of reference 3 Delusions of grandeur 4 Thought broadcasting

4 Thought broadcasting

A male patient on a psychiatric unit admits to obtaining sexual gratification by wearing his wife's clothing. Which type of sexual disorder do these symptoms indicate? 1 Pedophilia 2 Frotteurism 3 Homosexuality 4 Transvestic fetishism

4 Transvestic fetishism

The nurse is caring for a patient who is depressed and has complaints of insomnia. Which action by the patient would the nurse encourage to promote sleep? 1 Avoiding naps unless they are planned 2 Eating six small meals per day 3 Avoiding physical activity 4 Drinking diet soda

1 Avoiding naps unless they are planned

The nurse is caring for a patient suffering from major depression. Which activity by the patient should the nurse encourage to promote self-esteem in the patient? 1 Bowling 2 Football 3 Volleyball 4 Basketball

1 Bowling

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. For which signs and symptoms of this syndrome would the nurse be monitoring? Select all that apply. 1 Diaphoresis 2 Hyperrigidity 3 Hyperthermia 4 Photosensitivity 5 Agranulocytosis

1 Diaphoresis 2 Hyperrigidity 3 Hyperthermia

The nurse is caring for a patient with bipolar disorder. What should the nurse expect to be prescribed to the patient to manage the mood swings of this disorder? 1 Lithium carbonate 2 Phenelzine sulfate 3 Fluoxetine 4 Alprazolam

1 Lithium carbonate

A patient is diagnosed with obsessive-compulsive disorder. Which treatment possibilities does the nurse expect for the patient? Select all that apply. 1 Psychotherapy 2 Desensitization 3 Reality therapy 4 Electroconvulsive therapy 5 Drug therapy with clomipramine

1 Psychotherapy 5 Drug therapy with clomipramine

The nurse is caring for a patient who has bipolar disorder and experiences mood swings, psychomotor overactivity, and insomnia. Which interventions should the nurse use to communicate with this patient? Select all that apply. 1 Reinforce assertive behavior. 2 Ask directly about hallucinations. 3 Avoid expression of negative thoughts. 4 Encourage the patient to make decisions. 5 Encourage alternative ways to cope with stress.

1 Reinforce assertive behavior. 4 Encourage the patient to make decisions. 5 Encourage alternative ways to cope with stress.

Which nursing interventions should the nurse follow for a patient reporting hallucinations and delusions for more than 1 month? Select all that apply. 1 Report the positive behaviors. 2 Report the negative behaviors. 3 Give instructions one at a time. 4 Orient the patient back to reality. 5 Set limits for the patient's behavior.

1 Report the positive behaviors. 2 Report the negative behaviors. 4 Orient the patient back to reality.

The nurse finds that a patient has typical signs of schizophrenia without evidence of gross disorganization, concreteness, and hallucinations. Which type of schizophrenia is the patient suffering from? 1 Residual 2 Paranoid 3 Catatonic 4 Disorganized

1 Residual

A patient prescribed mirtazapine has developed hypertension. The nurse finds the patient was administered phenelzine sulphate 1 week ago. Which syndrome is suspected to cause the patient to develop hypertension? 1 Serotonin 2 Sundowning 3 Relocation stress 4 Neuroleptic malignant

1 Serotonin

A patient diagnosed with depression is prescribed fluoxetine. On assessment the nurse finds that the patient has a history of Parkinson's disease as well. Which risks are increased in the patient due to drug interactions? 1 Serotonin syndrome 2 Sundowning syndrome 3 Irritable bowel syndrome 4 Relocation stress syndrome

1 Serotonin syndrome

A 45-year-old woman is admitted to the psychiatric floor with a diagnosis of catatonic schizophrenia. Which assessment findings would be documented in the patient record to support this diagnosis? 1 Stupor, negativism, rigidity, posturing 2 Flat or inappropriate affect, incoherence 3 Rapid speech, decreased sleep, delusions that she is God 4 Delusional thoughts that nurses are trying to poison her with medication

1 Stupor, negativism, rigidity, posturing

A 45-year-old patient who lost a son in an accident is diagnosed with depression and has a risk of self-directed violence. Which outcome demonstrated by the patient does the nurse most likely expect if the nursing interventions are effective? 1 Interacts well with other patients 2 Denies having any suicidal thoughts 3 Sleeps at a scheduled time each night 4 Verbalizes ways of dealing with depression

2 Denies having any suicidal thoughts