Comprehensive Final

In which of the following situations would the nurse expect a client to exhibit symp- toms of increased anxiety? Select all that apply. 1. A client has a thyroid-stimulating hormone level of 0.03 mIU/L. 2. A client has a fasting glucose level of 60 mg/dL. 3. A client is experiencing caffeine intoxication. 4. A client has a diagnosis of gastroesophageal reflux disease. 5. A client is experiencing alcohol withdrawal syndrome.

1. A TSH level of 0.03 mIU/L is an indica- tion of hyperthyroidism. A major symp- tom of hyperthyroidism is high levels of anxiety. 2. A fasting glucose level of 60 mg/dL is an indication of hypoglycemia. One of the symptoms of hypoglycemia is a feeling of increased anxiety. 3. A client diagnosed with caffeine toxicity would show signs of anxiety because of the stimulant effects of caffeine. 5. A client going through alcohol withdrawal exhibits signs of increased anxiety.

Which of the following are tasks of the orientation phase of the nurse-client relation- ship? Select all that apply. 1. Establish a contract for intervention. 2. Identify client's strengths and limitations. 3. Problem solve situational crises. 4. Promote client's insight and perception of reality. 5. The formulation of nursing diagnostic statements.

1. A contract for intervention is a task of the orientation phase. The contract details the expectations and responsibilities of the nurse and the client. 2. The identification of the client's strengths and limitations occurs during the orientation phase. This assessment of the client's potential is necessary to intervene appropriately and in a timely manner. 5. The formulation of nursing diagnostic statements is one of the tasks of the orientation phase. A nursing diagnosis is a statement of assessed client problems, which occurs in the orientation phase.

Which of the following factors places a client at high risk for a suicide attempt? Select all that apply. 1. A previous suicide attempt. 2. Access to lethal methods. 3. Isolation. 4. Lack of a physical illness. 5. Impulsive or aggressive tendencies.

1. A history of previous suicide attempts places a client at higher risk for future attempts. 2. The ability to access a lethal means to commit suicide increases a client's risk for a suicide attempt. 3. Withdrawal and isolative behaviors indi- cates the client is experiencing hopeless- ness and helplessness, which increases the client's risk for a suicide attempt. 5. A client is at an increased risk for suicide if the client's behaviors tend to be impulsive or aggressive. These personality character- istics may lead a client to hasty, reckless decisions, which may include suicide.

A 60-year-old woman has been experiencing delusions of persecution, a depressed mood, and flat affect for 6 months. Which of the following factors would rule out a diagnosis of schizophrenia at this time? Select all that apply. 1. A medical condition has not been assessed and ruled out. 2. The client complains of depressed mood. 3. The client's age is not typical. 4. The client is experiencing the negative symptom of a flat affect. 5. The client is a woman.

1. A possible medical condition has not been assessed, and this could potentially rule out the diagnosis of schizophrenia. According to the DSM-IV-TR criteria for this diagnosis, the thought disturbance cannot be due to the direct physiological effects of a substance or a general medical condition. 2. Schizoaffective disorder and mood disor- ders with psychotic features must be ruled out for the client to meet the criteria for the diagnosis of schizophrenia. No major depressive, manic, or mixed episodes should have occurred concurrently with the active-phase symptoms. If mood episodes have occurred during the active- phase symptoms, their total duration should have been brief relative to the duration of the active and residual periods. 3. Symptoms of schizophrenia generally appear in late adolescence or early adult- hood. The client's age is outside this range and makes a diagnosis of schizo- phrenia unlikely.

Which of the following drinking patterns in the United States can be beneficial? Select all that apply. 1. When alcohol enhances the flavor of food. 2. When alcohol promotes celebration at special occasions. 3. When alcohol is used in religious ceremonies. 4. When alcohol helps mask stressful situations. 5. When alcohol is used to cope with unacceptable feelings.

1. Alcohol does enhance the flavor of foods and can be enjoyed with a good meal. 2. Alcohol is used at social gatherings to encourage relaxation and conviviality among guests. It can promote a feeling of celebration at special occasions, such as weddings, birthdays, and anniversaries. 3. An alcoholic beverage (wine) is used as part of the sacred ritual

A client monitored in an out-patient psychiatric clinic is taking clozapine (Clozaril) 50 mg bid. The white blood cell (WBC) count is 6000/mm3, and the granulocyte count is 1400/mm3. Based on these values, which nursing intervention is appropriate? 1. Stop the medication, and call the physician because of the low granulocyte count. 2. Stop the medication, and call the physician because of the low WBC count. 3. Give the medication because all of the lab values are normal. 4. Give the medication, and notify the physician to order a repeat WBC and granulocyte count.

1. Although the WBC count is normal, a granulocyte count of 1400/mm3 is less than 1500/mm3 and needs to be reported to the physician. The clozapine (Clozaril) would need to be discontinued.

The nurse would include which of the following biological interventions when caring for a client experiencing a panic? Select all that apply. 1. Monitor blood pressure and pulse. 2. Discuss situations surrounding past panic attacks. 3. Stay with the client when signs and symptoms of a panic attack are present. 4. Notify the client of the availability of alprazolam (Xanax) PRN. 5. Educate the client regarding how temperament affects anxiety disorders.

1. Blood pressure and pulse increase during panic attacks. Monitoring these vital signs is a biological intervention when caring for clients experiencing panic attacks. 4. Notifying the client of the availability of alprazolam (Xanax) PRN is a biological intervention when caring for clients expe- riencing panic attacks.

A client diagnosed with bipolar disorder has been taking lithium carbonate (lithium) for 3 months. Which assessment data would make the nurse request a lithium level? 1. Blurred vision and vomiting. 2. Increased thirst and urination. 3. Drowsiness and dizziness. 4. Hypotension and arrhythmias.

1. Blurred vision and vomiting are beginning signs of lithium carbonate (lithium) toxici- ty. Other beginning signs include ataxia, tinnitus, persistent nausea, and severe diarrhea. These symptoms are seen at serum levels of 1.5 to 2 mEq/L.

In which situation is a client at risk for delayed or inhibited grief? 1. When a client's family expects the client to maintain normalcy. 2. When a client experiences denial during the first week after the loss. 3. When a client experiences anger toward the deceased within the first month after the loss. 4. When a client experiences preoccupation with the deceased for 1 year after the loss.

1. Clients are at risk for delayed or inhibited grief when they do not have the support of significant others to assist them through the mourning process. Instead of providing support to this client, this fami- ly, to meet their own needs, expects the client to maintain normalcy.

The nurse is teaching a 16-year-old girl, diagnosed with anorexia nervosa, about the potential risk for osteoporosis. Which statement by the client may indicate that further teaching about osteoporosis is necessary? 1. "I have high estrogen levels, and that is why I am not having periods." 2. "I have a high level of stress hormone, and this can affect my bones." 3. "I am not taking in enough calcium and my bones can be brittle." 4. "I'm young, so my bone mass hasn't reached its peak. That puts me at risk."

1. Female clients diagnosed with anorexia nervosa have low, not high, estrogen levels and experience amenorrhea. These low estrogen levels place clients at risk for osteoporosis. This client's statement does not indicate an understanding of this fact, and more teaching is necessary.

A shaman from the Iroquois tribe comes to the hospital to collaborate with his tribe member's physician. The physician attempts to shake hands. The shaman lightly touches the physician's hand, then quickly moves away. How should the physician interpret this gesture? 1. The shaman does not feel comfortable with touch. 2. The shaman does not believe in traditional medicine. 3. The shaman is angry that he was called away from his family. 4. The shaman is snubbing the physician.

1. Generally, Native Americans do not engage in small talk, touching, hugging, or demonstrative displays of emotion. Some Native Americans view the handshake as aggressive. A handshake may be accepted with a slight touch or just the passing of hands.

A client diagnosed with bipolar disorder states, "My mom has a history of depression". While teaching about predisposing factors, using a biological theory, which client statement indicates that teaching has been successful? 1. "I am going to weigh the pros and cons before having children." 2. "My negative thoughts about myself are making me worse." 3. "It is entirely my mother's fault that I have this disorder." 4. "I learned how to cope by watching my family interactions."

1. Genetic influences or predisposing factors are acquired through heredity. This client was at a higher risk because of family his- tory. The client's statement indicates awareness of the biological theory of genetic predisposition.

When a client experiences a manic episode, the nurse would expect to assess which of the following? Select all that apply. 1. Grandiosity. 2. Flight of ideas. 3. Pressured speech. 4. Frequent short naps for rest. 5. Psychomotor agitation.

1. Grandiosity is defined as irrational ideas regarding self-worth, talent, or power. The nurse would expect to assess grandiosity, which is one of the diagnostic criteria for mania. 2. Flight of ideas is defined as a continuous but fragmentary stream of talk. The gen- eral train of thought can be followed, but the direction is frequently changed, often by chance stimuli from the environment. Flight of ideas is often assessed in clients experiencing acute manic states. 3. Pressured speech is defined as loud and emphatic speech that is increased in amount, accelerated, and usually difficult or impossible to interrupt. Pressured speech is often assessed in clients experi- encing acute manic states. 5. Psychomotor agitation is defined as exces- sive restlessness and increased physical activity. Psychomotor agitation is often assessed in clients experiencing acute manic states.

A client is admitted to the emergency department for a fractured leg resulting from a fall. While taking a history, the nurse discovers that the client's father and grandfather died of complications of alcoholism. The client is now using alcohol to reduce stress. What statement is most likely true? 1. The client is in the prealcoholic phase of drinking patterns and has a genetic predis- position to alcoholism. 2. The client is in the early alcoholic phase of drinking patterns and has a biologic ten- dency to drink. 3. The client is in the crucial phase of drinking patterns and has learned from his fam- ily to reduce stress by drinking. 4. The client is in the chronic phase of drinking patterns and needs medication to detox safely from alcohol.

1. In the prealcoholic phase, alcohol is used to relieve everyday stress and tension. This client, because of family history, has a genetic predisposition toward alcoholism.

Which of the following rights are afforded to a client who is admitted to an in-patient psychiatric unit as a danger to self? Select all that apply. 1. The right to refuse medications. 2. The right to leave the locked facility at any time. 3. The right to expect treatment that does no harm. 4. The right to know the truth about his or her illness. 5. The right to be treated equally.

1. It is the right of a competent individual, whether voluntarily or involuntarily com- mitted, to refuse medications. Medications can be forced only when a client is assessed as an imminent danger to self or others or declared incompetent by the court. 3. The ethical principle of nonmaleficence requires that health-care workers do no harm to their clients, either intentionally or unintentionally. 4. The ethical principle of veracity requires that health-care providers tell the truth and not intentionally deceive or mislead clients. 5. The ethical principle of justice requires that all clients be treated equally.

A client diagnosed with antisocial personality disorder is facing a 20-year prison term. The client has been prescribed sertraline (Zoloft) for depressed mood. Which inter- vention would take priority? 1. Monitor the client for suicidal ideations related to depressed mood. 2. Discuss the need to take medications, even when symptoms improve. 3. Instruct the client about the risks of stopping the medication abruptly. 4. Remind the client that it takes 4 to 6 weeks for the medication's full effect to occur.

1. Monitoring the client for suicidal ideations related to depressed mood would be the priority nursing intervention for a client experiencing depressed mood. Risk for client injury always should be pri- oritized. Assessing suicidal ideation is necessary for the nurse to intervene appropriately.

A client diagnosed with bipolar II disorder is experiencing hypomania. The client is not hostile, but is talking nonstop and disrupting an educational session. The client is forcibly taken to the client's room and placed in four-point restraints. Which principles are violated in this scenario? Select all that apply. 1. The principle of nonmaleficence. 2. The principle of veracity. 3. The principle of least restrictive treatment. 4. The principle of beneficence. 5. The principle of negligence.

1. Nonmaleficence is the right to expect the health-care worker to do no harm. By unnecessarily placing the client in four- point restraints, psychological and poten- tially physical harm may occur. 3. The right to least restrictive treatment applies in this situation. If the client is not an imminent danger to self or others, four-point restraints are not warranted. 4. Beneficence is the right to expect the health-care worker to promote the good of the client. Placing the client in four- point restraints, when the client is not a danger to self or others, does not promote the client's welfare. 5. Negligence is the failure to do something that a reasonable individual, guided by considerations that ordinarily regulate human affairs, would do, or doing some- thing that a prudent and reasonable indi- vidual would not do. By unnecessarily placing the client in four-point restraints, the nurse could be held responsible for committing a negligent act because four- point restraints are not indicated in this situation.

Thiamine deficiency is a major problem for clients diagnosed with alcohol dependence. Of the presenting signs and symptoms caused by this deficiency, what is most life- threatening? 1. Paralysis of ocular muscles, diplopia, ataxia, somnolence, and stupor. 2. Impaired mental functioning, apathy, euphoria or depression, sleep disturbance, increasing confusion leading to coma. 3. Nausea and vomiting, anorexia, weight loss, abdominal pain, jaundice, edema, ane- mia, and blood coagulation abnormalities. 4. Impaired platelet production and risk for hemorrhage.

1. Paralysis of ocular muscles, diplopia, atax- ia, somnolence, and stupor all are symp- toms of Wernicke's encephalopathy. This is the most serious form of thiamine defi- ciency in clients diagnosed with alco- holism. If thiamine replacement therapy is not undertaken quickly, death results.

The nurse is assessing a client diagnosed with an autism disorder. According to Mahler's theory of object relations, which describes the client's unmet developmental need? 1. The need for survival and comfort. 2. The need for awareness of an external source of fulfillment. 3. The need for awareness of separateness of self. 4. The need for internalization of a sustained image of a love object/person.

1. Phase 1 (birth to 1 month), is the Normal Autism phase of Mahler's development theory. The main task of this phase is sur- vival and comfort. Fixation in this phase may predispose a child to autistic disorders.

Which situation would place a client at high risk for a life-threatening hypertensive crisis? 1. A client is prescribed phenelzine (Nardil) and fluoxetine (Prozac). 2. A client is prescribed phenelzine (Nardil) and warfarin sodium (Coumadin). 3. A client is prescribed phenelzine (Nardil) and docusate sodium (Colace). 4. A client is prescribed phenelzine (Nardil) and metformin (Glucophage).

1. Phenelzine (Nardil) is an MAOI and can- not be taken with other antidepressants, such as fluoxetine (Prozac).

A client diagnosed with panic disorder has a nursing diagnosis of social isolation R/T fear. Using a cognitive approach, which nursing intervention is appropriate? 1. During a panic attack, remind the client to say, "I know this attack will last only a few minutes." 2. Discuss with the client the situation before the occurrence of a panic attack. 3. Encourage the client to acknowledge two trusted individuals who can assist the client during a panic attack. 4. Remind the client to use a journal to express feelings surrounding the panic attack.

1. Reminding a client to challenge his or her thought process in ways such as, "I know this attack will only last a few minutes," is an intervention that supports a cognitive approach.

A client diagnosed with post-traumatic stress disorder after a rape states, "Even though I know it is important, I just can't go to my gynecologist." Which nursing diagnosis reflects this client's problem? 1. Post-trauma syndrome R/T previous rape AEB unrealistic fear. 2. Noncompliance R/T trauma AEB avoiding yearly examination. 3. Knowledge deficit R/T importance of follow-up care AEB canceled appointment. 4. Altered health maintenance R/T no yearly gynecological exam AEB canceled appointment.

1. The client in the question is expressing unrealistic fears resulting from a previous trauma. The client's behaviors are being negatively influenced by these fears. This is evidence of the nursing diagnosis

A client becomes agitated in group therapy and yells; "You are all making me worse!" Which would be an appropriate response from the group leader? 1. "You sound angry and frustrated. Can you tell us more about it?" 2. "Maybe you would like to go to another group from now on." 3. "We will talk more about this during our individual session." 4. "What do the other group members think?"

1. The leader first wants to appreciate the client's feelings by using the therapeutic technique of "attempting to translate into feelings." The group leader then asks a focusing question that assesses the situa- tion further.

What is the basis for providing psychiatric/mental health nursing care? 1. The recognition and identification of functional patterns of response to actual or potential client problems. 2. The gathering of client data related to psychiatric illness, mental health problems, and potential comorbid physical illnesses. 3. The focusing of nursing interventions on the diagnoses described in the DSM IV- TR. 4. Assisting the physician in the delivery of comprehensive holistic client care.

1. The psychiatric/mental health nurse ana- lyzes data to determine client problems. The problem statement, or nursing diag- nosis, is the client's response to actual or potential problems, and is the basis and underlying objective of nursing interven- tions. Just as the physician cannot treat a client without knowing the medical diag- nosis, the nurse cannot provide care to a client without an understanding of the client's functional problems.

A client diagnosed with major depression has a nursing diagnosis of low self-esteem. Which is an appropriate short-term outcome related to this diagnosis? 1. The client will verbalize two positive things about self by day 2. 2. The client will exhibit increased feelings of self-worth by day 3. 3. The client will set realistic goals and try to reach them. 4. The client will demonstrate a decrease in fear of failure.

1. The verbalization of strengths is a short- term goal related to a nursing diagnosis of low self-esteem. The client first must be aware of what they like about themselves before other long-term goals are set.

A client diagnosed with somatization pain disorder is admitted to an in-patient psychiatric unit. Which client statement would the nurse assess as evidence of primary gain? 1. "Experiencing severe back pain has taken my mind off my pending divorce." 2. "My mom only listens to me when I am complaining about the pain." 3. "Because of my pain disorder, I had to apply for disability." 4. "When I tell people about my pain, they are very sympathetic to my situation."

1. This client is using pain as a method to avoid anxiety related to feelings of rejec- tion associated with a pending divorce. This is an example of a primary gain.

What etiological implication reflects social learning theory? 1. Modeling and identification can be observed from early childhood in individuals exhibiting substance abuse behaviors. 2. An individual is encouraged to continue substance abuse because of the pleasure experienced during use. 3. A son of an alcoholic father has a four times greater incidence of developing alcoholism. 4. Identical twins have twice the rate for concordance of alcoholism compared with fraternal twins.

1. This etiological implication is from a social learning perspective based on family influence.

According to the DSM-IV-TR, which disorder includes the diagnostic criteria of pat- terns of negativity, disobedience, and hostile behavior toward authority figures? 1. Separation anxiety disorder. 2. Oppositional defiant disorder. 3. Narcissistic personality disorder. 4. Autistic disorder.

2. A child diagnosed with oppositional defi- ant disorder presents with a pattern of negativity, disobedience, and hostile behavior toward authority figures. This pattern of behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. This disorder typically begins by 8 years of age, and usually not later than adolescence. The disorder is more preva- lent in boys than in girls and is often a developmental antecedent to conduct disorder.

Believing in the dignity and worth of a client is to respect as acceptance and a nonjudg- mental attitude are to: 1. Trust 2. Rapport 3. Genuineness 4. Empathy

2. Acceptance and a nonjudgmental attitude toward clients reflect the concept of rap- port. Establishing rapport creates a sense of harmony based on knowledge and appreciation of each individual's unique- ness. The ability to care for and about others is the core of rapport.

A client is exhibiting sedation, auditory hallucinations, akathisia, and anhedonia. The client is prescribed haloperidol (Haldol) 5 mg tid, and trihexyphenidyl (Artane) 4 mg bid. Which statement about these medications is accurate? 1. The trihexyphenidyl (Artane) would address the client's auditory hallucinations. 2. The trihexyphenidyl (Artane) would counteract the akathisia. 3. The haloperidol (Haldol) would address the anhedonia. 4. The haloperidol (Haldol) would decrease the amount of sedation exhibited.

2. Akathisia, an extrapyramidal symptom, is restlessness, a side effect of the use of antipsychotic medications such as haloperidol (Haldol). Trihexyphenidyl (Artane) is prescribed to address uncom- fortable restlessness.

The nurse is planning care for a client with a long history of crack abuse who has recently been admitted to the substance abuse unit. The nurse intentionally keeps the treatment plan simple. What is the underlying rationale for this decision? 1. The client would be unable to focus because of the use of denial. 2. The client is at high risk for mild to moderate cognitive problems. 3. Physical complications would impede learning. 4. The client has arrested in developmental progression.

2. Approximately 40% to 50% of substance- dependent individuals have mild to mod- erate cognitive problems when actively using. These cognitive problems would necessitate the use of a simple treatment plan that would be more readily under- stood by the client.

A client experiencing dementia is becoming increasingly agitated and confused. Which intervention should the nurse implement first? 1. Request a physician's order for lab tests to rule out infection. 2. Assess the client's vital signs and any obvious physiological changes. 3. Call pharmacy to determine possible medication incompatibilities. 4. Document the findings, and notify the oncoming shift regarding the situation.

2. Assessing the client's vital signs and any obvious physiological changes alerts the nurse to immediate problems the client may be experiencing. The physician, when notified, would need access to the client's vital signs and presenting symptoms before formulating instructions and orders.

Which assessment data support the diagnosis of obsessive-compulsive disorder? 1. The client's thoughts, impulses, or images are excessive worries about real-life problems. 2. The client is aware at some point during the course of the disorder that the obsessions or compulsions are excessive or unreasonable or both. 3. The obsessions or compulsions experienced significantly interfere with only one area of function. 4. The client represses thoughts, impulses, or images, and substitutes other thoughts or behaviors.

2. At some point during the course of the disorder, a client diagnosed with OCD becomes aware that the obsessions or compulsions are excessive or unreasonable or both.

A nurse is assessing a client in the mental health clinic. For 3 weeks, the client has been exhibiting eccentric behaviors with blunted affect. There is impairment in the client's role functioning. These symptoms are reflective of which phase in the development of schizophrenia? 1. Phase I—schizoid personality. 2. Phase II—prodromal phase. 3. Phase III—schizophrenia. 4. Phase IV—residual phase.

2. Characteristics of the prodromal phase include social withdrawal; impairment in role functioning; eccentric behaviors; neg- lect of personal hygiene and grooming; blunted or inappropriate affect; distur- bances in communication; bizarre ideas; unusual perceptual experiences; and lack of initiative, interests, or energy. The length of this phase varies, and this phase may last for many years before progress- ing to schizophrenia. The symptoms described in the question are reflective of the prodromal phase of the development of schizophrenia.

Which factor is associated with the etiology of attention-deficit hyperactivity disorder (ADHD) from a genetic perspective? 1. Inborn error of metabolism. 2. Having a sibling diagnosed with ADHD. 3. A possible dopamine neurotransmitter deficit. 4. Retarded id development.

2. Children diagnosed with ADHD are more likely than normal children to have sib- lings who also are diagnosed with the dis- order. Studies also reveal that when one twin of an identical twin has ADHD, the other is likely to have it too. Other studies have indicated that many parents of hyperactive children showed signs of hyperactivity during their own childhoods. These studies support a genetic etiology for the diagnosis of ADHD.

A client is diagnosed with alcoholic dementia. What nursing intervention is appropri- ate for this client's nursing diagnosis of altered sensory perception? 1. Assess vital signs. 2. Decrease environmental stimuli. 3. Maintain a nonjudgmental approach. 4. Empathetically confront denial.

2. Decreasing the amount of stimuli in the client's environment (e.g., low noise level, few people, simple décor) lowers the pos- sibility that a client diagnosed with alco- holic dementia will form inaccurate sensory perceptions.

A client diagnosed with schizophrenia is experiencing emotional ambivalence. When the nurse educates the client's family, which would best describe this symptom? 1. An inward focus on a fantasy world. 2. The simultaneous need for and fear of intimacy. 3. Impairment in social functioning, including social isolation. 4. The lack of emotional expression.

2. Emotional ambivalence experienced by the client diagnosed with schizophrenia refers to the coexistence of opposite emo- tions toward the same object, person, or situation. These opposing emotions may interfere with the client's ability to make a simple decision. The simultaneous need for and fear of intimacy interferes with the establishment of satisfying relation- ships.

A nurse is discharging a client diagnosed with obsessive-compulsive personality disor- der. Which employment opportunity is most likely to be recommended by the treat- ment team? 1. Home construction. 2. Air traffic controller. 3. Night watchman at the zoo. 4. Prison warden.

2. Individuals diagnosed with obsessive-compulsive personality disorder are inflexible and lack spontaneity. They are meticulous and work diligently and patiently at tasks that require accuracy and discipline. They are especially concerned with matters of organization and efficiency, and tend to be rigid and unbending about rules and procedures, making them good candidates for the job of air traffic controller.

A client is experiencing hyperventilation, depersonalization, and palpitations. Which nursing diagnosis takes priority? 1. Social isolation. 2. Ineffective breathing pattern. 3. Risk for suicide. 4. Fatigue.

2. Ineffective breathing pattern is defined as inspiration or expiration that does not provide adequate ventilation. This is a life-threatening problem that must be pri- oritized immediately.

A client with a long history of alcoholism has been recently diagnosed with peripheral neuropathy. What nursing diagnosis addresses this client's problem? 1. Altered coping R/T substance abuse AEB a long history of alcoholism. 2. Pain R/T effects of alcohol AEB complaints of 6/10 pain. 3. Powerlessness R/T substance abuse AEB no control over drinking. 4. Altered sensory perception R/T effects of alcohol AEB visual hallucinations.

2. Peripheral neuropathy is characterized by peripheral nerve damage resulting in pain, burning, tingling, or prickly sensations of the extremities. Pain related to the effects of alcohol as evidence by rating pain as a 6 out of 10 on a pain scale is a nursing diag- nosis that addresses this client's problem.

A client is newly admitted to an in-patient psychiatric unit. The following nursing diagnoses are formulated for this client. Which of these would the nurse prioritize? 1. Defensive coping R/T dysfunctional family process. 2. Risk for self-directed violence R/T depressed mood. 3. Impaired social interactions R/T lack of social skills. 4. Anxiety R/T fear of hospitalization.

2. Safety is always a priority. Risk for self- directed violence, if not addressed, puts the client's safety at risk. This diagnosis is especially important to look at when an individual is newly admitted to an in- patient psychiatric unit.

A client has been admitted to an in-patient psychiatric unit expressing suicidal ideations and complains of insomnia and feelings of hopelessness. During an admission assessment, which nursing intervention takes priority? 1. Using humor in the interview to uplift the client's mood. 2. Evaluating blood work, including thyroid panel and electrolytes. 3. Teaching the client relaxation techniques. 4. Evaluating any family history of mental illness.

2. Some comorbid disorders that contribute to depression, such as endocrine or elec- trolyte disturbances, need to be ruled out before a client can be diagnosed with depression. If these imbalances were detected, solving these problems would take priority.

A client admitted to an inpatient psychiatric unit has given written informed consent to participate in a medication research study. The client states, "I have changed my mind and don't want to take that medication." Which is the priority nursing intervention? 1. Tell the client that once the forms are signed, the client must continue with the research. 2. Tell the client that withdrawal from the research can be done at any time. 3. Tell the client that he or she should have not been allowed to participate because of a thought disorder. 4. Tell the client that he or she can withdraw only if the physician gives permission.

2. The client can change his or her mind and drop out of a study at any time.

A client diagnosed with body dysmorphic disorder has a nursing diagnosis of self-esteem disturbance. Which short-term outcome is appropriate for this nursing diagnosis? 1. The client will participate in self-care by day 5. 2. The client will express two positive attributes about self by day 3. 3. The client will demonstrate one coping skill to decrease anxiety by day 4. 4. The client will interact with peers in school during this fall semester.

2. The client's ability to express two positive attributes about self by day 3 is a short- term, measurable outcome that is reflec- tive of the nursing diagnosis of self- esteem disturbance.

A client diagnosed with anorexia nervosa is forced into the emergency department by a family member. During the intake assessment, this family member answers all questions posed to the client. Which nursing intervention is appropriate at this time? 1. Allow the family member to continue directing the conversation to gather critically needed information. 2. Empathize with the family member and communicate the need to gain information directly from the client. 3. Request that the physician ask the family member to wait outside during the assessment. 4. Request an evaluation by a social worker to assist with interpersonal conflicts.

2. The family member is rightfully con- cerned about this client; the nurse should communicate understanding and empathy. It also is important to communicate the need to gain assessment information from the client's perspective, factoring in the client's right to privacy. Because clients diagnosed with anorexia nervosa have a distorted self-image, after obtaining client permission, it may be necessary to involve family to attain accurate information.

A client admitted to an in-patient psychiatric unit following a manic episode is pre- scribed lithium carbonate (lithium) 300 mg bid. Which serum lithium levels would the nurse expect on discharge? 1. 0.9 mEq/L. 2. 1.4 mEq/L. 3. 1.9 mEq/L. 4. 2.4 mEq/L.

2. The level necessary for managing acute mania is 1 to 1.5 mEq/L, and 1.4 mEq/L is within the range for managing acute mania experienced by the client during hospitalization.

A client is diagnosed with a somatization disorder. When planning care, which nursing intervention should be included? 1. Avoid discussing symptoms experienced. 2. Encourage exploration of the source of anxiety. 3. Remind the client about previous negative test results. 4. Redirect the client to the physician when somatic complaints are expressed.

2. The nurse must plan care that encourages exploration of the underlying anxiety experienced by the client. Because anxiety is unconsciously expressed through somatic symptoms, it is the nurse's responsibility to assist the client to begin to understand the link between anxiety and somatic symptoms.

A client states, "I know that the night nurse has cast a spell on me." Which nursing diagnosis reflects this client's problem? 1. Disturbed sensory perception. 2. Disturbed thought process. 3. Impaired verbal communication. 4. Social isolation.

2. The nursing diagnosis of disturbed thought processes is defined as the dis- ruption in cognitive operations and activi- ties. An example of a disturbed thought process is a delusion. The statement by the client in the question is an example of a persecutory delusion, which is one form of altered thought process.

The student nurse is learning about dissociative identity disorder. Which student statement indicates that learning has occurred? 1. "Individuals with dissociative identity disorder are unable to function in social or occupational situations." 2. "The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress." 3. "Dissociative identity disorder is an Axis II diagnosis, commonly called multiple personality disorder." 4. "All personalities are aware of one another, and events that take place are known by all the different personalities."

2. The transition from one personality to another is usually sudden, often dramatic, and usually precipitated by stress. The time during personality transition is usu- ally a matter of seconds, and some behav- ioral symptoms, such as blinking of the eyes, facial changes,

A client states, "After retirement, my husband divorced me, and my children left for college." The nurse responds, "It sounds to me like you are feeling pretty lonely." Which is a description of the therapeutic techniques used by the nurse? 1. Giving the client the opportunity to collect and organize thoughts. 2. Helping the client to verbalize feelings that are being indirectly expressed. 3. Striving to explain that which is vague or incomprehensible. 4. Repeating the main idea of what the client has said.

2. This is a description of the therapeutic technique of "verbalizing the implied." When the nurse states, " You are feeling pretty lonely," the nurse is "verbalizing the implied" by presenting what the client has hinted at or suggested.

Which client statement would best support the nursing diagnosis of ineffective coping R/T recent loss of spouse? 1. "I use the gym to take my mind off of my loss." 2. "A glass or two of wine before bedtime helps me sleep." 3. "My doctor prescribed Ambien for 1 week to help me sleep at night." 4. "I know I need help, and therapy can help me get through this rough time."

2. This is an example of ineffective coping because alcohol is a central nervous system depressant that decreases mood and may lead to dependency.

A client diagnosed with an antisocial personality disorder has the nursing diagnosis of ineffective coping R/T parental neglect AEB "I broke the jerk's arm, but he deserved it." Which short-term outcome is appropriate for this client's problem? 1. The client will be able to delay immediate gratification after discharge from the hospital. 2. The client will verbalize understanding of unit rules and consequences for infrac- tions by end of shift. 3. The client will eventually have insight into negative behaviors and establish mean- ingful relationships. 4. The client will verbalize personal responsibility for difficulties experienced in inter- personal relationships within the year.

2. This short-term outcome is stated in observable and measurable terms. This outcome sets a specific time for achievement (by end of shift), it is specific (rules and consequences), and it is written in positive terms, all of which should contribute to the final outcome of the client having an increased ability to cope appropriately.

The nurse focuses on exploration of alternatives rather than providing answers or advice. This is one of the many strategies of nonthreatening feedback. Which nursing statement is an example of this strategy? 1. "You should sign up for the AA meetings to help in your recovery." 2. "Let's discuss previously successful coping mechanisms you might try after dis- charge." 3. "I have found that others with problems like yours need an AA sponsor." 4. "You need a hobby to get your mind off of alcohol."

2. This statement by the nurse helps the client focus on and explore alternatives, rather than providing answers or solutions that may be unacceptable to the client.

Which situation would place a client at high risk for a life-threatening hypertensive crisis? 1. A client is prescribed isocarboxazid (Marplan) and drinks orange juice. 2. A client is prescribed tranylcypromine (Parnate) and takes a diet pill. 3. A client is prescribed isocarboxazid (Marplan) and has Cheerios for breakfast. 4. A client is prescribed tranylcypromine (Parnate) and has oatmeal for breakfast.

2. Tranylcypromine (Parnate) is an MAOI, and if taken with diet pills would cause a life-threatening hypertensive crisis.

An adolescent diagnosed with major depression has a nursing diagnosis of social isolation. This client is currently attending groups and communicating with staff. Which statement evaluates this client's behavior accurately? 1. The nurse is unable to evaluate this adolescent's ability to socialize, based on the observed behaviors. 2. The client is experiencing a positive outcome exhibited by group attendance and communication with staff. 3. The nurse is unable to evaluate this adolescent's ability to socialize because the client has not experienced these behaviors for an extended period. 4. Attending group and communicating with staff is an indication of improved self- esteem, not improved social isolation.

2. When the adolescent attends group and communicates with staff members, the adolescent is experiencing improved socialization skills, making this an accu- rate evaluative statement.

A child diagnosed with Tourette's disorder has a nursing diagnosis of impaired social interaction R/T impulsive oppositional and aggressive behavior. The child is currently able to interact with staff members and peers using age-appropriate, acceptable behaviors. Which statement evaluates this child's behavior accurately? 1. The nurse is unable to evaluate this child's ability to interact socially, based on the observed behaviors. 2. The child is experiencing improved social interaction as evidenced by interacting with staff and peers by using age-appropriate, acceptable behaviors. 3. The nurse is unable to evaluate this child's ability to interact socially because the child has not experienced these behaviors for an extended period. 4. Interacting with staff and peers by using age-appropriate, acceptable behaviors is an indication of improved self-esteem, not improved social interaction.

2. When the child uses age-appropriate, acceptable behaviors to interact with staff members and peers, this child is experi- encing improved social interaction, mak- ing this an accurate evaluative statement.

The nurse is interacting with a client on the in-patient unit. The client states, "Most forward action grows life double plays circle uniform." Which charting entry should the nurse document about this exchange? 1. "Client is experiencing circumstantiality." 2. "Client is communicating by the use of word salad." 3. "Client is communicating tangentiality." 4. "Client is perseverating."

2. Word salad is a group of words that are strung together in a random fashion, without any logical connection. The client's statement is an example of the use of word salad.

A client diagnosed with generalized anxiety disorder is getting ready for discharge. Which statement evaluates the client's cognitive response to nursing interventions? 1. "The client appears calm, vital signs within normal limits, no diaphoresis noted." 2. "The client states that the breathing techniques used helped to decrease anxiety." 3. "The client is able to recognize negative self-talk as a sign of increased anxiety." 4. "The client uses journaling to express frustrations."

3. A client's recognizing negative self-talk as a sign of increased anxiety is an example of a cognitive response to nursing inter- ventions.

In which situation is a client at highest risk for lorazepam (Ativan) overdose? 1. The client exhibits increased tolerance. 2. The client experiences depression and anxiety. 3. The client combines the drug with alcohol. 4. The client takes the drug with antacids.

3. Alcohol has an additive central nervous system depression effect with the benzo- diazepine and can cause an individual to overdose. Also, individuals who are under the influence of alcohol or any illicit drug have an increase in impulsivity and poor decision making, which place them at higher risk for overdose.

A client with a short history of heavy drinking is seen in the emergency department. The client has a pulse rate of 120 beats/min, respirations of 24/min, and blood pres- sure of 180/90 mm Hg, and is diaphoretic and tremulous. The client is confused and picks at extremities. What would be the suspected cause of these symptoms? 1. Wernicke-Korsakoff syndrome. 2. Alcoholic amnestic disorder. 3. Alcohol withdrawal delirium. 4. Acute alcoholic myopathy.

3. Alcohol withdrawal delirium is character- ized by tremors, agitation, anxiety, diaphoresis, increased pulse and blood pressure, sleep disturbances, hallucina- tions, seizures, delusions, and delirium tremens. Delirium tremens is the most severe expression of alcohol withdrawal syndrome. It is characterized by visual, auditory, or tactile hallucinations; extreme disorientation; restlessness; and hyperac- tivity of the autonomic nervous system. The client in the question is experiencing tactile hallucinations, among other symp- toms of alcohol withdrawal delirium.

What drug is commonly prescribed for clients diagnosed with narcolepsy? 1. Barbiturates. 2. Analgesics. 3. Amphetamines. 4. Benzodiazepines.

3. Amphetamines stimulate the CNS and are used in the management of narcolepsy, attention-deficit disorders, and weight control.

A client diagnosed with a thought disorder is having trouble expressing fears of dis- charge to the treatment team. Functioning in the role of an advocate, which is an appropriate nursing response? 1. "Would you like me to explain how to increase your assertiveness skills?" 2. "Let's see how you have effectively communicated to the team in the past." 3. "I'll be with you when you talk to the team. I'll remind you of your concerns." 4. "I can appreciate how stressful it is to the talk to the team. Let's discuss it."

3. Being present as a support person and offering to remind clients of their con- cerns is the functional role of the nurse advocate.

The nurse is evaluating a client diagnosed with an antisocial personality disorder. Which client statement is reflective of this diagnosis? 1. "I feel so guilty about hurting her, but I just lost control." 2. "I'm very afraid when the voices tell me to kill myself." 3. "I don't have a problem. It's your problem for misunderstanding." 4. "I find it easier to be alone than with my family."

3. Clients diagnosed with antisocial person- ality disorders do not have insight into self-pathology and tend to blame other people and circumstances for their inter- personal problems.

When assessing a client diagnosed with paranoid personality disorder the nurse might identify which characteristic behavior? 1. A lack of empathy. 2. Shyness and emotional coldness. 3. Suspiciousness without justification. 4. A lack of remorse for hurting others.

3. Clients diagnosed with paranoid personal- ity disorder present with a pervasive dis- trust and suspiciousness of others and are preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

An extremely suicidal client needs to be admitted to the locked psychiatric unit. There are no beds available. Which client would the nurse anticipate that the treatment team would discharge? 1. A client involuntarily committed 2 days ago with situational depression. 2. A client voluntarily committed 2 days ago for alcohol detoxification. 3. A client voluntarily committed 4 days ago with delirium owing to a urinary tract infection. 4. A client involuntarily committed with command hallucinations.

3. Delirium is a reversible condition. Because the urinary tract infection is the cause of the delirium, by day 4 antibiotics should have stabilized this client's condi- tion. This makes this client a candidate for discharge.

A client, diagnosed with an antisocial personality disorder, is given a nursing diagnosis of defensive coping R/T a dysfunctional family system AEB denial of obvious problems and weaknesses. Which client statement would confirm this nursing diagnosis? 1. "I know what I did was wrong, and I understand the consequences." 2. "I don't see how I can afford follow-up therapy." 3. "I'm an angel compared with the rest of my family." 4. "I go to church, but only when it suits me."

3. Denial of obvious problems and weakness, along with projection of inappropriate behaviors onto others, is indicative of defensive coping and would confirm

A client states, "I don't know why I'm depressed; my husband takes care of all my needs. I don't even have to write a check or get a driver's license." Based on this statement, this client is most likely to be diagnosed with which personality disorder? 1. Schizoid personality disorder. 2. Histrionic personality disorder. 3. Dependent personality disorder. 4. Passive-aggressive personality disorder.

3. Dependent personality disorder (cluster C) is characterized by allowing others to assume responsibility for major areas of life because of one's inability to function independently. Although the client expresses satisfaction with her present situation, dependency lends itself to decreased self-esteem, self-worth, and motivation, and, eventually, depression.

Which client suicide plan would be considered most lethal? 1. "While my husband is sleeping, I will swallow 30 Zoloft." 2. "Although I don't own a gun, I am going to shoot myself." 3. "In the middle of nowhere, there's a high bridge that I can jump from at night." 4. "I will take 10 Tylenol with Codeine right before my husband comes home."

3. In this situation, the client has access to the bridge, the means to carry out the plan, and less likelihood of being rescued. In relation to the other plans presented, this plan is the most lethal.

A client with which personality disorder characteristically chooses solitary activities, seems indifferent to praise and criticism, and has deficits in the ability to form personal relationships or to respond to others in any meaningful way? 1. Schizotypal personality disorder. 2. Paranoid personality disorder. 3. Schizoid personality disorder. 4. Histrionic personality disorder.

3. Individuals diagnosed with schizoid per- sonality disorder display a lifelong pattern of social withdrawal, and their discomfort with human interaction is very apparent. Approximately 3% to 7.5% of the popula- tion has this disorder. The gender ratio of this disorder is unknown, although it is diagnosed more frequently in men.

During an interaction with a nurse, a client, although interacting appropriately, does not make eye contact. Which is a true statement about nonverbal communication? 1. Nonverbal communication is controlled by the conscious mind. 2. Nonverbal communication carries less weight than what the client says. 3. Nonverbal communication does not have the same meaning for everyone. 4. Nonverbal communication generally is a poor reflection of what the client is feeling.

3. Interpreting nonverbal communication can be problematic. Sociocultural back- ground is a major influence on the mean- ing of nonverbal behavior. Some cultures may consider eye contact intrusive, threatening, or harmful and minimize or avoid its use. Nonverbal communication includes all of the five senses and every- thing that does not involve the spoken word.

Structure is a component of milieu therapy. Which interaction is reflective of this com- ponent? 1. Affirmations of a client's individual self-worth are therapeutic. 2. Flexible patterns and varied schedules provide opportunities for growth. 3. Level systems can provide clients with opportunities to earn privileges. 4. Decreased demands on clients reduce stress.

3. Level systems can be used as a form of structure in milieu therapy.

A client is diagnosed with obsessive-compulsive personality disorder. In which cluster would this personality disorder be categorized, and on which axis of the DSM-IV-TR multiaxial evaluation system would the nurse expect to find this documentation? 1. Cluster C, axis I. 2. Cluster B, axis II. 3. Cluster C, axis II. 4. Cluster B, axis I.

3. Obsessive-compulsive personality disorder is grouped in cluster C and is correctly addressed on Axis II. Personality disorders and mental retardation usually begin in childhood or adolescence and persist in a stable form into adulthood.

Difficulty initiating or maintaining sleep is to insomnia as parasomnia is to: 1. Sleep disorders that are misaligned between sleep and waking behaviors. 2. Excessive sleepiness or seeking excessive amounts of sleep. 3. Unusual and undesirable behaviors that occur during sleep. 4. Temporary cessation of breathing while sleeping.

3. Parasomnias are the unusual to undesir- able behaviors that occur during sleep. Examples are nightmare disorder, in which an individual's frightening dream leads to an awakening from sleep; sleep terror disorder, in which an individual abruptly arouses from sleep with a pierc- ing scream or cry; and sleepwalking, in which an individual may leave the bed and walk about, dress, go to the bathroom, talk, scream, or even drive. This motor activity is performed while the individual remains asleep.

While the nurse is completing an initial interview with a client in the emergency department, the client admits to recent drug use. What area of assessment should take priority? 1. The client's chief complaint. 2. A complete history and physical examination. 3. Type of drugs used. 4. Family history.

3. Symptoms of substance overdose or with- drawal vary in intensity and can be life- threatening. In this situation, it is critical to assess the substance used to provide individualized, safe, and effective care.

Which of the following tools is used to assess for tardive dyskinesia? 1. The CAGE assessment tool. 2. Global Assessment of Functioning (GAF) scale. 3. The Abnormal Involuntary Movement Scale (AIMS). 4. Clock face assessment.

3. The AIMS is a scale to assess for tardive dyskinesia, a syndrome of symptoms char- acterized by bizarre facial and tongue movements, a stiff neck, and difficulty swallowing. AIMS is a comparative scale documenting changes over time.

A client has an IQ level of 30. Which client cognitive/educational capability would the nurse expect to observe? 1. The client is capable of academic skills to second-grade level. 2. The client, with supervision, may respond to minimal training in self-help. 3. The client would profit only from systematic habit training. 4. The client is capable of academic skills to sixth-grade level.

3. The client in the question has been diag- nosed with severe mental retardation (IQ level 20 to 34). This client would be unable to profit from academic or voca- tional training, but might profit from sys- tematic habit training.

The nurse is interviewing a client who is experiencing a nihilistic delusion. Which client statement confirms the presence of this symptom? 1. "The doctor says I'm not pregnant, but I know that I am." 2. "Someone is trying to get a message to me through the articles in this magazine." 3. "The world no longer exists." 4. "The FBI has 'bugged' my room, and they intend to kill me."

3. The client's statement, "The world no longer exists," is an example of a nihilistic delusion. A nihilistic delusion is when an individual has a false idea that the self, a part of the self, others, or the world is nonexistent.

Which situation reflects the defense mechanism of displacement? 1. A disgruntled employee confronts and shouts at his boss. 2. A disgruntled employee takes his boss and his wife out to dinner. 3. A disgruntled employee inappropriately punishes his son. 4. A disgruntled employee tells his son how much he likes his job and boss.

3. The disgruntled employee considers his son less threatening than his boss and is transferring his negative feelings from one target to another by using the defense mechanism of displacement.

A client diagnosed with major depressive disorder is prescribed bupropion (Wellbutrin) and sertraline (Zoloft). The client states, "Why am I on two antidepressants?" Which is the best nursing response? 1. "The bupropion assists the client with smoking cessation while the sertraline treats depressive symptoms." 2. "Sertraline assists with the negative side effects of bupropion." 3. "The medications treat the symptoms of depression through different mechanisms of action." 4. "Both medications help with symptoms of anxiety along with depression."

3. The practitioner prescribed a medication that affects only serotonin, sertraline (Zoloft), and a medication that effects norepinephrine and dopamine, bupropion (Wellbutrin). When the practitioner pre- scribes this combination of medications, all three neurotransmitters, believed to be altered in major depressive disorder, are affected. Tricyclic antidepressants also affect all three neurotransmitters; however, they have been found to have more side effects and are less tolerated than a com- bination of these newer agents.

Which is an example of the therapeutic technique of "exploring"? 1. "Was this before or after. . . . ?" 2. "And after that you. . . . ?" 3. "Give me an example of . . . ." 4. "How does that compare with. . . . ?"

3. This is the therapeutic technique of exploring. Exploring delves further into a subject or an idea, and allows the nurse to examine experiences or relationships more fully. Asking for an example can clarify a vague or generic statement.

The nurse focuses on feedback that is client-centered rather than focusing on feedback that meets the nurse's needs. This is one of the many strategies of nonthreatening feed- back. Which nursing statement is an example of this strategy? 1. "I had an eating disorder when I was 16. Let me tell you how I felt." 2. "It upsets me to see your mother so worried about you." 3. "Tell me about how you feel when you purge?" 4. "My friends teased me in high school, and I ignored them. Why not try that?"

3. This statement focuses on the needs of the client, and not the needs of the nurse.

What information is important to teach a client who has recently been prescribed ziprasidone (Geodon) 40 mg bid PO? 1. "It may take 4 to 6 weeks to see full effect on bothersome symptoms." 2. "You need to have blood work done every 2 weeks to monitor for agranulocytosis." 3. "Make sure you take this medication with food because a full stomach assists with absorption." 4. "Use diet and regular exercise to reduce the potential weight gain caused by the medication."

3. Ziprasidone (Geodon) needs to be taken on a full stomach to help with absorption.

Which describes the therapeutic communication technique of "focusing"? 1. Being fully present for a client as information is gathered. 2. Verification of assumed meaning. 3. Repetition of the main meaning. 4. Concentration on one particular theme.

4. "Focusing" is the therapeutic technique in which the nurse takes particular notice of a single idea, word, or theme. The nurse directs the communication exchange to draw the client's attention to the meaning and significance of a theme in the com- munication process.

On an in-patient psychiatric unit, a nurse is completing a risk assessment on a newly admitted client with increased levels of anxiety. The nurse would document which cognitive symptom expressed by the client? 1. Gritting of the teeth. 2. Changes in tone of voice. 3. Increased energy. 4. Misperceptions of stimuli.

4. A misperception of stimuli, such as mis- taking a handshake for an aggressive act, is a cognitive sign the nurse would want to document during a risk assessment.

A client diagnosed with AIDS becomes confused, and has fluctuating memory loss, difficulty concentrating, and diminished motor speed. Which would be the probable cause of this client's symptoms? 1. Impaired immune response. 2. Persistent generalized lymphadenopathy 3. Kaposi's sarcoma. 4. AIDS dementia complex.

4. AIDS dementia complex affects 40% to 60% of clients diagnosed with this debili- tating disease and is a common cause of mental status change in clients diagnosed with HIV infection. Typical manifesta- tions of AIDS dementia complex are con- fusion, fluctuating memory loss, decreased concentration, lethargy, and diminished motor speed.

Which intervention is a nurse's priority when working with a client suspected of having a conversion disorder? 1. Avoid situations in which secondary gains may occur. 2. Confront the client with the fact that anxiety is the cause of physical symptoms. 3. Teach the client alternative coping skills to use during times of stress. 4. Monitor assessments, lab reports, and vital signs to rule out organic pathology.

4. In this situation, it is a priority for the nurse to monitor assessments, lab tests, and vital signs to rule out organic pathol- ogy. It is important for the nurse not to presume that a psychological problem exists before a physical disorder is thor- oughly evaluated.

A client newly admitted to an in-patient psychiatric unit is diagnosed with major depressive disorder. Which nursing diagnosis is a priority at this time? 1. Social isolation R/T fear of failure. 2. Imbalanced nutrition, less than body requirements R/T depressed mood. 3. Powerlessness R/T a lifestyle of helplessness. 4. Low self-esteem R/T fear of abandonment.

4. Low self-esteem is defined as a long- standing negative self-evaluation or nega- tive feelings about self or self-capabilities. Feelings of low self-esteem are typical of clients diagnosed with major depressive disorder. Low self-esteem can lead to deficits in self-care. If the client's self- esteem improves, other problems, such as social isolation, powerlessness, and imbal- anced nutrition, also should improve; therefore, this diagnosis can be prioritized.

A nursing instructor is teaching the neurochemical effects of escitalopram (Lexapro). Which statement, by the student, indicates an understanding of the content presented? 1. "Lexapro increases the amount of norepinephrine available in the synapse." 2. "Lexapro encourages the reuptake of norepinephrine at the postsynaptic site." 3. "Lexapro encourages the reuptake of serotonin at the postsynaptic site." 4. "Lexapro increases the amount of serotonin available in the synapse."

4. SSRIs inhibit the reuptake of serotonin and allow for more serotonin to be avail- able in the synapse.

A client on an in-patient psychiatric unit is overheard stating, "I visited Miss Emma yesterday while I was out on a pass with my family." What would the nurse expect to assess as a positive finding in this client's urine drug screen? 1. Heroin. 2. Oxycodone. 3. Phencyclidine (PCP). 4. Morphine.

4. Street names for morphine include Miss Emma, M., and white stuff.

A physically abused child diagnosed with conduct disorder bullies and threatens peers on a psychiatric unit. Which nursing diagnosis would take priority? 1. Risk for self-mutilation R/T to low self-esteem. 2. Ineffective individual coping R/T physical abuse. 3. Impaired social interaction R/T neurological alterations. 4. Risk for violence: directed at others R/T displaced anger.

4. Studies reveal that children diagnosed with conduct disorder have a history of abuse, neglect, and the frequent shifting of parental figures, which then is dis- placed in aggression toward others. This aggression has been found to be the prin- cipal cause of peer rejection, contributing to a cycle of maladaptive behavior. Because the possibility of harm to others is so great, the nursing diagnosis risk for violence: directed at others would take priority at this time.

What statement is correct regarding clients with a dual diagnosis? 1. The substance abuse issue must be addressed first. 2. The mental health issue must be addressed first. 3. Dual diagnosis is not possible. Only one Axis I diagnosis can be assigned. 4. The primary focus must be on a holistic view of the client's problems.

4. Substance abuse and any other diagnosis of mental disorder must be treated con- cordantly to provide holistic client care. Both should be a priority consideration.

Which is a behavior that influences sleep patterns? 1. Sleep requirements increase during mental stress. 2. During periods of intense learning, more sleep is required. 3. Adolescents tend to sleep late, and older adults awake early. 4. Sleep can be used to avoid stressful situations.

4. The behavioral factor of using sleep to avoid stressful situations influences sleep patterns.

Which statement about attention-deficit hyperactivity disorder (ADHD) is true? 1. ADHD is characterized by a persistent pattern of withdrawal into self. 2. ADHD is frequently diagnosed before age 2 years. 3. ADHD occurs equally among girls and boys. 4. ADHD is characterized by a persistent pattern of inattention.

4. The essential feature of ADHD is a per- sistent pattern of inattention or hyperac- tivity-impulsivity, or both, that is more frequent and severe than is typically observed in individuals at a comparable level of development.

A client is discussing plans to have a serum lithium carbonate (Lithium) level taken on discharge. To obtain an accurate serum level, which discharge teaching information should be included? 1. Remind the client to take lithium carbonate (lithium) as prescribed before the serum level is drawn. 2. Remind the client to have the serum level drawn while fasting at least 12 hours. 3. Remind the client to notify the physician if the client is exhibiting any signs and symptoms of toxicity. 4. Remind the client to have a serum level drawn 12 hours after taking a dose of lithium carbonate (lithium).

4. The nurse needs to stress the importance of having the serum lithium level drawn 12 hours after the client's last dose for accurate monitoring. It is important that the client understand that the level can be altered if this instruction is not followed. Clients can be in danger of relapse or toxicity if their serum lithium levels are inaccurate.

A client on a psychiatric unit has continually told the treatment team, "I am not respon- sible for the break-up of my marriage." Which client statement would indicate that the client is ready to collaborate with the team? 1. "Okay, I'll agree to talk about her, but you have to know that this is her fault." 2. "My mother supports me, and in my heart, I know you'll support me too." 3. "You make me feel special. You kind of look like my wife." 4. "Okay, let's sit down and talk to my wife and work out a counseling plan."

4. This example of collaboration embraces the treatment team and client working together and becoming involved in the client's goals and plan of care. Collaboration has great relevance in psychiatric nursing, and encourages clients to recognize their own problems and needs.

Which nursing intervention within the community is aimed at reducing the prevalence of psychiatric illness by shortening the duration of the illness? 1. Teaching techniques of stress management. 2. Providing classes on parenting skills. 3. Providing education and support to the homeless. 4. Staffing suicide hotlines.

4. This nursing intervention, at the second- ary prevention level, is focused on reduc- ing the prevalence of psychiatric illness by shortening the duration of the illness. An individual calling a suicide hotline is expe- riencing suicidal ideations, and the staff member provides currently needed care to address the symptom.

A 16-year-old client has complaints of binge eating, abuse of laxatives, and feeling "down" for the last 6 months. Which statement is reflective of this client's symptoms? 1. The client meets the criteria for an Axis I diagnosis of bulimia nervosa. 2. The client meets the criteria for an Axis I diagnosis of anorexia nervosa. 3. The client needs further assessment to be diagnosed using the DSM-IV-TR. 4. The client is exhibiting normal developmental tasks according to Erikson.

81. 1. Included in the diagnostic criteria for bulimia nervosa is binge eating; inappro- priate behavior to prevent weight gain, such as the abuse of laxatives; and poor self-evaluation. These symptoms must occur, on average, at least twice a week for 3 months. This client meets the criteria for an Axis I diagnosis of bulimia nervosa.

Of women who give birth, ___% to ___% experience "the blues."

Of women who give birth, 50% to 80% experi- ence "the blues." Moderate depression occurs in 10% to 16%, and severe or psychotic depression occurs in about 1 or 2 out of every 1000 post- partum women. Symptoms of the "maternity blues" include tearfulness, despondency, anxiety, and subjectively impaired concentration occur- ring in the early puerperium. The symptoms usually begin 3 to 4 days after delivery, worsen by days 5 to 7, and tend to resolve by day 12. Symptoms of moderate postpartum depression have been described as depressed mood varying from day to day, with more bad days than good, tending to be worse toward evening and associ- ated with fatigue, irritability, loss of appetite, sleep disturbances, and loss of libido.

Using Kubler-Ross's model of the normal grief response, number the following stages of grief in order. ___ Depression ___ Bargaining ___ Acceptance ___ Denial ___ Anger

The correct order is 4, 3, 5, 1, 2. Kubler- Ross's five stages of grief consist of (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. Behaviors associated with each of these stages can be observed in indi- viduals experiencing the loss of any concept of personal value. These stages typically occur in the order presented; however, there may be individualized variations in how the grieving progresses.

A client diagnosed with aquaphobia begins a therapeutic process in which the client must stand in a pool for 1 hour. This is called _______________ therapy.

This is called implosion therapy. Implosion therapy, or "flooding," is a therapeutic process in which the client must participate for a long time in real-life or imagined situations that he or she finds extremely frightening. A session is termi- nated when the client responds with consider- ably less anxiety than at the beginning of the session. A client diagnosed with aquaphobia, the fear of water, begins the therapeutic process in which the client must stand in a pool for 1 hour.