Exam 2: Intracranial Pressure & Psychosis

Name that Extra Pyramidal Side Effect (EPSE): Sudden, sustained contraction of one or several muscle groups, usually of the head and neck. these can be frightening, cause significant anxiety, and should be treated promptly.

Answer: Acute Dystonia Rationale: dys- = meaning "ill," "bad," "abnormal;" -tonia = meaning "muscle tension, nerve tension."

The nurse is planning a group session for three chronically ill clients who have the diagnosis of schizophrenia. In light of the symptoms and general characteristics of schizophrenia and long-term mental illness, what is one of the most helpful topics for this group? 1) Relaxation techniques 2) Rational behavior therapy 3) Assertiveness in relationships 4) Social skills in the group setting

Answer: Rationale: Chronically ill clients with schizophrenia usually have a lack of social skills, so this topic is appropriate for this group. Relaxation techniques can be helpful for anyone; however, this is not the most therapeutic focus for this group. Rational behavior therapy is helpful for clients coping with depression. Many chronically mentally ill clients have difficulty applying the concepts associated with being assertive.

While a nurse is assisting with morning care for a client with the diagnosis of schizophrenia, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior? 1) Somatic delusion 2) Paranoid ideation 3) Loose association 4) Ideas of reference

Answer: 1 Rationale: A SOMATIC DELUSION is a false feeling about the physical self that is caused by a loss of reality testing. PARANOID IDEATIONS are beliefs that the individual is being singled out for unfair treatment. LOOSE ASSOCIATIONS are verbalizations that are difficult to understand because the links between thoughts are not apparent. IDEAS OF REFERENCE are false beliefs that the words and actions of others are concerned with or are directed toward the individual.

A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt? 1) By palpating the anterior fontanel 2) By determining the frequency of voiding 3) By assessing the child for periorbital edema 4) By assessing the symmetry of the Moro reflex

Answer: 1 Rationale: A bulging fontanel is the most significant sign of increased intracranial pressure in an infant. Periorbital edema, the frequency of voiding, and the symmetry of the Moro reflex are not indicators of increased intracranial pressure. In infants, other early manifestations of increased ICP include separated cranial sutures, irritability and restlessness, drowsiness, increased sleeping, high-pitched cry, increased head circumference, distended scalp veins, poor feeding, crying when disturbed, and setting-sun sign.

An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles (483 km) away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit? 1) "Around 2:30 in the afternoon is the best time to visit." 2) "Whenever it is most convenient for you. She'll be glad to see you." 3) "Come at noon. You'll be able to go to the dining room and visit while she eats." 4) "The longest uninterrupted time begins after supper and extends until bedtime, at 8:30."

Answer: 1 Rationale: A client with dementia will be most alert in the midafternoon because of the presence of sunlight and decreased activity in the environment. Telling the daughter to come whenever it is most convenient for her does not take into consideration the client's circadian rhythms and stressors within the environment that may affect the client. As environmental stimuli increase, the client is at risk for increased confusion, restlessness, agitation, and combative behavior. The evening (after supper and continuing until bedtime, at 8:30 pm) is when the sundown syndrome occurs; clients with dementia exhibit increased confusion, restlessness, agitation, wandering, and combative behavior because of misinterpretation of the environment, lower tolerance for stress at the end of the day, or overstimulation resulting from increased environmental activity in the evening.

Which food should be avoided by a client who is prescribed monoamine oxidase inhibitors (MAOIs)? 1) Bologna 2) Potatoes 3) Citrus fruit 4) Grapefruit juice

Answer: 1 Rationale: Bologna has a high tyramine content; tyramine should not be consumed by clients taking monoamine oxidase inhibitors (MAOIs) because the drug interaction may cause severe hypertension.

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? 1) Assess the client's airway 2) Place pads on the side rails 3) Notify the HCP 4) Leave and obtain the crash cart

Answer: 1 Rationale: Ensuring an airway is the first action in an emergency response to any client (ABCs!). Placing pads on the side rails during the procedure is too late; protecting the airway and client are priority. The healthcare provider will be notified as soon as the nurse ensures the client's safety and has a patent airway. The nurse should not leave the client during a seizure.

Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia? 1) Screening a group of male patients between the ages of 15 and 25 for early symptoms. 2) Forming a support group for females age 25 to 35 who are diagnosed with substance use issues. 3) Providing a group for patients between the ages of 45 and 55 with information on coping skills that have proven to be effective. 4) Educating the parents of a group of developmentally delayed 5- to 6-year-olds on the importance of early intervention.

Answer: 1 Rationale: Onset in males is usually between the ages of 15 and 25 years and is associated with poor functioning and more structural abnormalities in the brain. The onset tends to be somewhat later in women, ages 25 to 35 years; women tend to have a better prognosis and experience less structural changes in the brain.

Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia? 1) Always afraid another student will steal her belongings. 2) An unusual interest in numbers and specific topics. 3) Demonstrates no interest in athletics or organized sports. 4) Appears more comfortable among males.

Answer: 1 Rationale: Risk factors in the prodromal phase include high levels of stress and substance abuse. Interventions focused on enhancing social and coping skills can reduce the risk for developing schizophrenia in biologically vulnerable people.

A client with schizophrenia, undifferentiated type, is receiving a typical antipsychotic/neuroleptic. The nurse will assess for which extrapyramidal effects? 1) Shuffling gait, tremors, and restlessness 2) Nausea, vomiting, and muscle cramps 3) Drowsiness, disorientation, and slurred speech 4) Tachycardia, urine retention, and constipation

Answer: 1 Rationale: Shuffling gait, tremors, and restlessness are common extrapyramidal signs (pseudoparkinsonism) that occur as side effects of neuroleptics; they are usually controlled with antiparkinsonian drugs. Nausea, vomiting, and muscle cramps are signs of lithium toxicity. Drowsiness, disorientation, and slurred speech are common side effects that occur with central nervous system depressants. Tachycardia, urine retention, and constipation are common side effects that occur with antidepressants.

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, where does the nurse suspect the tumor is located? 1) Cerebellum. 2) Parietal lobe. 3) Basal ganglia. 4) Occipital lobe.

Answer: 1 Rationale: The cerebellum is involved in synergistic control of the skeletal muscles and the coordination of voluntary movement (1). The parietal lobe is concerned with localization and two-point discrimination; tumors here cause motor seizures and sensory function loss (2). Basal ganglia are concerned with large subconscious movements and muscle tone; damage here may cause paralysis, as in a brain attack, or involuntary movements and uncontrollable shaking, as in Parkinson disease (3). The occipital lobe is concerned with special sensory perception; tumors here cause visual disturbances, visual agnosia, or hallucinations (4).

A male client with a history of schizophrenia comes to the emergency department, accompanied by his wife. What is the emergency department nurse's priority intervention? 1) Observing and evaluating his behavior. 2) Writing a plan of care for the mental health team. 3) Obtaining a copy of the client's past medical records. 4) Meeting separately with his wife and exploring why he came to hospital.

Answer: 1 Rationale: The client and his needs are the priority, and assessment is the first step of the nursing process. Writing a plan of care for the mental health team is done after a thorough assessment is completed. The nurse must deal with the present, not the past. Although meeting separately with the wife should be done, it is not the priority.

A 25-year-old man is admitted to the psychiatric unit after being found by the police walking naked down the middle of the street at 3:00 AM. He insists that he is the real Santa Claus. Which of the following nursing interventions should the nurse implement when working with this patient? 1) Consistently use the patient's name. 2) Point out to the patient why he cannot be Santa Claus. 3) Agree that he is Santa Claus so as not to upset him further. 4) Provide medication as needed (PRN).

Answer: 1 Rationale: The patient needs continuous reality-based orientation, so his name should be used in all interactions with the nurse and other staff. The nurse should not reinforce the delusion by agreeing with the patient. Logical arguments and PRN medication are not likely to change his thinking.

While watching television in the dayroom, a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? 1) Walking to the end of the hallway where the client is standing. 2) Accepting the action of the impulsive behavior of a sick person. 3) Asking another client in the day room why the client acted in this way. 4) Documenting the incident and the client's record while the memory is fresh.

Answer: 1 Rationale: Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client.

A 50-year-old female patient is admitted to the psychiatric unit for an acute exacerbation of paranoid schizophrenia after she stopped taking her medications for several months. She tells the nurse that she believes her food is being poisoned, and she refuses to eat. What is the most appropriate intervention by the nurse? 1) Provide canned food while expressing reasonable doubt. 2) Agree with the patient's decision. 3) Challenge the patient's delusion. 4) Dismiss her fears and insecurities.

Answer: 1 Rationale:Highly suspicious patients may refuse to eat food from an individually prepared tray. While not reinforcing the patient's delusion by agreeing with it, providing canned food may be an acceptable alternative to ensure proper nutrition. Challenging the delusion may increase the patient's anxiety. Dismissing her fears and insecurities invalidates the patient's emotional state.

A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? 1) Hypoxemia 2) Hyperthermia 3) Emotional trauma 4) Aspiration pneumonia

Answer: 1 Rationale:The degree of hypoxia experienced by the child will determine the extent of neurological, liver, and renal damage. The child was hypothermic, not hyperthermic. Although emotional trauma can be overwhelming, it usually does not influence the ultimate physical prognosis as the extent of the hypoxia does. Although aspiration pneumonia may be severe initially, it does not result in long-term sequelae as hypoxia can.

Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is OK, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2F. What are the priority nursing interventions? Select all that apply. 1) Hold his medication and contact his prescriber. 2) Wipe him with a washcloth white with cold water or alcohol. 3) Administer a medication, such as benztropine IM, to correct his dystonic reaction. 4) Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. 5) Hold his medication for now and consult his prescriber when he comes to the unit later today.

Answer: 1, 2 Rationale: Kyle is experiencing symptoms of Anticholinergic Toxicity, which is a potentially life-threatening medical emergency. Nursing care and considerations include holding all medications (1), consulting a prescriber immediately (1), implementing emergency cooling measures as ordered (2); administer benzodiazepine (ie. a sedative) or physostigmine (ie. an antidote to reverse anticholinergic effects) as ordered. (Benztropine is in a class of medications called anticholinergic; administration of benztropine would worsen this situation.)

When conducting a health history, the nurse identifies some of the following social risk factors as possible predictors of a diagnosis of schizophrenia. Select all that apply. 1) Urban residence 2) Recent immigration 3) Impaired physical or mental health 4) Older paternal age 5) First-degree relative diagnosed with schizophrenia 6) Ethnic and racial discrimination

Answer: 1, 2, 6 Rationale: Urban residence, recent immigration, and ethnic and racial discrimination are social conditions that have been implicated as risk factors for developing schizophrenia. Although the other factors are also considered to be risk factors, they are not classified as social predictors.

Which antipsychotic drugs have the higher risk of causing tardive dyskinesia? Select all that apply. 1) Loxapine 2) Quetiapine 3) Haloperidol 4) Ziprasidone 5) Olanzapine

Answer: 1, 3 Rationale: First-generation antipsychotic drugs such as loxapine and haloperidol may cause tardive dyskinesia, an extrapyramidal reaction. Second-generation antipsychotic drugs such as quetiapine, ziprasidone, and olanzapine have a lower risk of causing extrapyramidal reactions.

A client is admitted to a psychiatric unit with the diagnosis of schizophrenia, undifferentiated type. When assessing the client, the nurse identifies the presence of several characteristics related to this disorder. What may this include? Select all that apply. 1) Bizarre behavior. 2) Extreme negativism. 3) Disorganized speech. 4) Persecutory delusions. 5) Auditory hallucinations.

Answer: 1, 3, 5 Rationale: Undifferentiated schizophrenia meets general the criteria, but does not fall into any subtype; includes at least one positive and one negative symptom. Bizarre behavior (+), disorganized speech (+), and auditory hallucinations (+) are associated with UNDIFFERENTIATED schizophrenia. Extreme negativism (+) is associated with CATATONC schizophrenia. Persecutory delusions (+) are associated with PARANOID schizophrenia

When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply. 1) Slowing of the heart rate 2) Diminished carotid pulses 3) Bleeding from the oral cavity 4) Absence of deep tendon reflexes 5) Increased pulse pressure 6) Altered LOC

Answer: 1, 3, 5, 6 Rationale: Increased intracranial pressure from bleeding into and swelling of tissues within the cranium results in a slowing of the heart rate (1), an increased pulse pressure (5; due to increasing systolic blood pressure with a sustained diastolic blood pressure), and an altered level of consciousness (6). Bleeding from the oral cavity (3) can occur IN THIS SITUATION; the presence of cerebral spinal fluid should be assessed. Carotid circulation is not altered. Spinal reflexes generally remain intact.

An older client has been prescribed an atypical antipsychotic medication. Which nursing interventions demonstrate that the nurse has determined the client's risk for injury? Select all that apply. 1) Monitoring the pulse for an irregular rhythm. 2) Sitting with the client during meals to encourage eating. 3) Offering a favorite beverage between meals to maintain hydration. 4) Assessing the temperature to determine the possibility of an infection. 5) Teaching the client about the importance of taking an anticholinergic medication.

Answer: 1, 4 Rationale: Older clients prescribed atypical antipsychotic medications are at increased risk for death as a result of cardiovascular dysfunction and infection and should be monitored closely for such situations. This client is at risk for death related to complications of atypical antipsychotic medication therapy, but the risk is not related to poor nutrition, dehydration, or any condition that could be managed with anticholinergic therapy.

A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. 1) Slurred speech 2) Lability of mood 3) Long-term memory loss 4) Visual or tactile hallucinations 5) Insidious deterioration of cognition 6) A fluctuating level of consciousness

Answer: 1, 4, 6 Rationale: Delirium,a transient cognitive disorder caused by global dysfunction in cerebral metabolism, results in sparse or rapid speech that may be slurred and incoherent (1). Visual or tactile hallucinations and illusions may occur with delirium because of altered cerebral function (4). Clients with delirium fluctuate from hyperalert to difficult to arouse (6); they may lose orientation to time and place. Clients with delirium are consistently irritable, anxious, and fearful. Short-term memory loss is associated with both delirium and dementia; eventually long-term memory loss is associated with dementia. The onset of delirium is abrupt (hours to days) and has an organic basis; it is often precipitated by drugs such as anesthesia, analgesics, and antibiotics or by conditions such as infections, end-stage kidney disease, and substance abuse or withdrawal.

During a follow-up visit, the nurse finds increased intracranial pressure in a client who has undergone nasal hypophysectomy for hyperpituitarism. Which action taken by the client is responsible for this condition? 1) Using stool softeners. 2) Blowing the nose and sneezing. 3) Performing deep-breathing exercises. 4) Bending the knees and lowering the body to pick up objects.

Answer: 2 Rationale: A hypophysectomy is the surgical removal of the pituitary gland to treat cancerous or benign tumors. A client who underwent a hypophysectomy should be taught toperform activities that reduce ICP. Blowing the nose and sneezing can increase ICP. Constipation may result in ICP. Therefore, the client should be advised to take stool softeners and change to a high-fiber diet to prevent the risk of ICP. Performing deep breathing exercises can reduce ICP. Bending the knees and lowering the body to pick up objects reduces the risk of ICP

The nurse is talking with a delusional client who has been hospitalized for 2 weeks. In the middle of the conversation the client suddenly stops talking, seems preoccupied, and then states, "I hear voices." Because the nurse has already assessed the content of the hallucinations, what is the most therapeutic response? 1) Asking the client, "What are the voices saying?" 2) Telling the client, "I didn't hear any voices," and then focusing on the conversation. 3) Say nothing, remaining observant, and later documenting the incident in the client's record. 4) Challenging the client by emphasizing that there is no one else there and reminding the client that there are just the two of them.

Answer: 2 Rationale: A nonconfrontational validation of reality is the most therapeutic response that one can provide for a delusional client. Asking what the voices are saying enters into the client's delusion, which will strengthen the delusional system. Saying nothing is nontherapeutic because it does not interject reality into the incident. It is not therapeutic to directly challenge a client's delusion; it will not change the client's belief.

A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask a nurse, "How much longer will my child need to take the medication?" What is the best response by the nurse? 1) "Medications are continued for three years after the last seizure." 2) "It is important that the medications be gradually decreased." 3) "Medications are usually discontinued at the two-year follow-up visit." 4) "Seizure disorders are lifelong problems that require ongoing medications."

Answer: 2 Rationale: A predesigned protocol is used to wean a child off anticonvulsants gradually because ABRUPT REMOVAL OFF THE DRUG CAN RESULT IN SEIZURE. Anticonvulsants are discontinued gradually after a child is seizure free for 2 years (ie. NOT 3 years) and has an EEG within expected limits. Anticonvulsants cannot be stopped abruptly at the 2-year follow-up visit, but DICONTINUATION PROCESS may be started. The statement that seizure disorders are lifelong problems that require ongoing medications may or may not be true; this is determined on an individual basis.

A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs? 1) Lubricating the skin with baby oil 2) Suctioning the oropharynx routinely 3) Elevating the head of the bed 20° 4) Cleansing the eyes every 4 hours with normal saline

Answer: 2 Rationale: Although suctioning is done to maintain an airway, it is not done routinely because it increases intracranial pressure. The nurse should intervene to correct this behavior. All the rest are correct behaviors. Lubricating the skin keeps the skin from drying, which helps prevent skin breakdown. Elevating the head of the bed promotes venous return to the heart and is used to limit increased intracranial pressure. Instilling artificial tears every two hours is the appropriate intervention. The corneal reflex may be absent in the unconscious client; a dry cornea is prone to injury.

A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? 1) Residual 2) Paranoid 3) Catatonic 4) Disorganized

Answer: 2 Rationale: Clients with paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations and exhibit behavioral changes such as anger, hostility, or violence. Residual schizophrenia is characterized by the negative symptoms of schizophrenia, but the client does not experience delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia is a state in which the client displays extreme psychomotor retardation to the point of not talking or moving. There may be brief intermittent hyperactive episodes with catatonia. Disorganized schizophrenia is characterized by a disintegration of the personality and withdrawn behavior.

What is the function of a client's cranial nerve VI? 1) Movement of the eye with levator muscle 2) Movement of the eye with lateral rectus muscles 3) Movement of the eye with medial rectus muscles 4) Movement in the eye with superior oblique muscles

Answer: 2 Rationale: Cranial nerve VI (abducens) helps eye movement with the lateral rectus muscles. Cranial nerve III (oculomotor) helps in the lid elevation with the levator muscle. Cranial nerve III (oculomotor) helps in the eye movement with medial rectus muscles. Cranial nerve IV (trochlear) helps in eye movement with the superior oblique muscles.

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1) Increase socialization of the client with peers. 2) Avoid laughing or whispering in front of the client. 3) Begin to educate the client about social supports in the community. Have the client sign a release of information to appropriate parties for assessment purposes.

Answer: 2 Rationale: Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

The primary healthcare provider prescribes a neuroleptic drug to a client diagnosed with schizophrenia. On what basis would the primary healthcare provider choose the drug? 1) Symptoms 2) Side effects 3) Therapeutic effects 4) Underlying pathology

Answer: 2 Rationale: First-generation antipsychotic drugs are also known as neuroleptics. The selection of these drugs is primarily based on side effects rather than therapeutic effects. Because all symptoms respond equally to antipsychotic drugs, the drug selection may not be based on symptoms. Because these drugs do not alter the underlying pathology, the selection may not be based on underlying pathology.

Which drug most commonly causes extrapyramidal side effects (EPS)? 1) Clozapine 2) Haloperidol 3) Risperidone 4) Aripiprazole

Answer: 2 Rationale: Haloperidol is a typical antipsychotic that commonly causes extrapyramidal side effects. Clozapine is an atypical antipsychotic that has a low risk of causing extrapyramidal side effects. Risperidone and aripiprazole have a low risk of causing extrapyramidal side effects.

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? 1) Projection 2) Regression 3) Repression 4) Rationalization

Answer: 2 Rationale: Regression is the defense mechanism that is commonly used by clients with schizophrenia, (UNDIFFERENTIATED type), to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia (PARANOID type) in which the delusional system is well systematized.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do? 1) Hold the client's extremities firmly 2) Protect the client's head from injury 3) Insert an airway between the client's teeth 4) Have several staff members move the client to a soft surface

Answer: 2 Rationale: Rhythmic contraction and relaxation associated with a tonic-clonic seizure can cause repeated banging of the head. Holding extremities firmly is contraindicated because it can cause broken bones. Inserting an airway between the client's teeth is contraindicated because damage to the teeth can occur if force is used to insert an airway. Moving during a seizure can result in physical injuries; the client should be moved after the seizure.

What is a clinical manifestation of hypernatremia in burns? 1) Fatigue 2) Seizures 3) Paresthesia 4) Cardiac dysrhythmias

Answer: 2 Rationale: Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.

A client with an inoperable temporal lobe tumor is experiencing frightening auditory hallucinations, especially when alone. How can the nurse best help the client cope with these hallucinations? 1) By moving the client to a four-bed room closer to the nurses' station 2) By suggesting that the client turn on the radio or television when alone 3) By working out a schedule for visitors so the client will never be alone 4) By having family or friends remain with the client until the hallucinations stop

Answer: 2 Rationale: Stimuli such as a television or radio encourage the client to remain reality oriented; research has shown that competing stimuli are useful in controlling hallucinations.

A 56-year-old man is admitted to the inpatient unit after family members report that he seems to be experiencing auditory hallucinations. The man has a history of schizophrenia and has had several previous admissions. Which statement indicates to the nurse that the client is experiencing auditory hallucinations? 1) "Get these horrible snakes out of my room!" 2) "I am not the devil! Stop calling me those names!" 3) "The food on this plate has poison in it, so take it away—I won't eat it." 4) "I did see an alien spaceship last night outside in my yard, and I've felt worse ever since."

Answer: 2 Rationale: The client is responding to messages that he is hearing, which are auditory hallucinations. The responses regarding the snakes and the spaceship are examples of visual hallucinations because they describe what the client sees. The accusation of poisoning is the statement of a client who is suspicious and paranoid but not hallucinating.

Which instruction given by the nurse ensures good healing in a client recovering after surgical removal of the pituitary gland by endoscopic transnasal approach? 1) "Decrease fluid intake." 2) "Increase high-fiber food intake." 3) "Bend over from the waist to pick up fallen objects." 4) "Brush teeth regularly with a medium-bristle brush."

Answer: 2 Rationale: The nurse should instruct the client who is recovering after surgical removal of the pituitary gland to consume high-fiber food. ICP is raised if the client strains during defecation; fibrous foods reduce the risk of constipation and thereby reduce bowel strain. The client should be instructed to drink sufficient water to facilitate easy bowel movements and soften the stools. The nurse should teach the client to bend the knees and then lower the body to pick up fallen objects; bending at the waist increases ICP. The client should use dental floss and avoid brushing post-operatively for at least 2 weeks to prevent disturbance of the operative site.

A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit for 2 weeks is to be discharged home. The client is vacillating between being happy and sad about going home. What term best describes these conflicting emotions? 1) Double bind 2) Ambivalence 3) Loose Association 4) Inappropriate affect

Answer: 2 Rationale: The simultaneous existence of two conflicting emotions, impulses, or desires is known as AMBIVALENCE. A single communication containing two conflicting messages is known as a DOUBLE-BIND message. A lack of connections between thoughts is known as LOOSE ASSOCIATIONS. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.

On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be? 1) Ignoring the client at this time. 2) Stating that this behavior is unacceptable. 3) Moving him to his room for a short "time out." 4) Time the client to come to the office later to discuss the behavior.

Answer: 2 Rationale: When clients enter a new milieu, limits should be set on unacceptable behavior and acceptable behavior should be reinforced. Neither clients nor unacceptable behavior should ever be ignored. Moving the client to his room for a short time-out is punishment. Unacceptable attention-getting behavior must be addressed immediately; also, the focus should be on appropriate behavior.

A client who had a tonic-clonic seizure of unknown etiology is to begin taking phenytoin. What instructions will the nurse give to the client? 1) Take the medication on an empty stomach 2) Brush the teeth and gums 3 times daily 3) Stop taking the drug if abdominal pain occurs 4) Note any changes in pulse and respiratory rates

Answer: 2 Rationale:Adequate dental hygiene is essential to control or prevent the common side effect of hypertrophy of the gums. The medication should be taken with food or milk to decrease gastrointestinal side effects. The healthcare provider should be consulted before the drug is discontinued or the dosage is adjusted; usually in this situation, a gradual dosage reduction is prescribed. Changes in pulse and respiratory rates are unrelated to phenytoin therapy.

A delusional client has refused to eat for the past 24 hours, saying "the food is poisoned." How should the nurse respond? 1) "Why do you think that the food is poisoned?" 2) "You feel worried that someone wants to poison you?" 3) "This feeling is a symptom of your illness. It's not real." 4) "You'll be safe with me. I won't let anyone poison you."

Answer: 2 Rationale:It is important to help the client focus on feelings, and "You feel worried that someone wants to poison you?" is the only response that helps achieve this goal (2). Why questions call for a conclusion rather than an exploration of the issue; the client may not have the answer (1). Although stating that the feeling is a symptom of the client's illness is true, it is not something that the client is ready to understand; also, it is a closed statement (3). "You'll be safe with me. I won't let anyone poison you" is false reassurance and is not realistic; the client still is concerned about what will happen when the nurse is not there (4).

A client has been taking 3 mg of risperidone twice a day for the past 8 days. At the follow-up appointment, the client reports tremors, shortness of breath, a fever, and sweating. What will the nurse do? 1) Call 911 and have the client transported to the nearest psychiatric unit. 2) Take the client's vital signs and arrange for immediate transfer to a hospital. 3) Check the number of risperidone tablets left in the prescription bottle to see whether there was an overdose. 4) Request a prescription for 2 mg of intramuscular benztropine stat and assess the client in 10 to 15 minutes for symptom relief.

Answer: 2 Rationale:These clinical manifestations signal the presence of NEUROLEPTIC MALIGNANT SYNDROME; the cardinal sign of this condition is a high body temperature. Therefore, the nurse first should document the hyperthermia and then arrange for immediate hospitalization. Unless the client is experiencing impaired ventilation, it is important to complete a focused assessment before transfer. T

A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to dementia? Select all that apply. 1) Slurred speech 2) Lability of mood 3) Long-term memory loss 4) Visual or tactile hallucinations 5) Insidious deterioration of cognition 6) A fluctuating level of consciousness

Answer: 2, 3, 5 Rationale: Clients with dementia may be confused and disoriented; hallucinations are not prominent with dementia. Lability of mood is associated with dementia (2). Short-term memory loss is associated with both delirium and dementia; eventually long-term memory loss is associated with dementia (3). The onset of dementia is slow and insidious (years; 5).

While watching television, a 28-year-old male patient appears to be hallucinating. He is swearing loudly at the television and is becoming increasingly agitated. Which of the following nursing interventions would be appropriate in dealing with this patient? 1) In a firm voice, tell the patient to stop this behavior. 2) Acknowledge the presence of the hallucinations. 3) Instruct other team members to ignore the patient's behavior. 4) Reassure the patient that he is not in any danger. 5) Give simple commands in a calm voice.

Answer: 2, 4, 5 Rationale:Using a calm voice and giving simple commands, the nurse should reassure the patient that he is not in any danger. It is not appropriate to tell the patient to stop the behavior, and ignoring the behavior will not reduce his agitation.

Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply. 1) Optic (CN II) 2) Facial (CN VII) 3) Trochlear (CN IV) 4) Accessory (CN XI) 5) Trigeminal (CN V)

Answer: 2, 5 Rationale: Facial (CN VII): Sensory of pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two-thirds of the tongue; Motor functions of the face and scalp. Trigeminal (CN V): Sensory perception from the skin of the face, scalp, and mucous membranes of the mouth and nose; Motor functions of this nerve include mastication.Optic (CN II): Sensory of eye; Trochlear (CN IV): Motor functions of eye movement via superior oblique muscles; Accessory (CN XI): Motor functions of skeletal muscles of the pharynx, larynx, sternocleidomastoid, and trapezius muscles.

A client with schizophrenia is receiving intramuscular injections of fluphenazine decanoate. After therapy is initiated, dystonia develops. What clinical manifestations does the nurse document during the assessment? Select all that apply. 1) Akathisia 2) Torticollis 3) Shuffling gait 4) Masklike facies 5) Oculogyric crisis

Answer: 2, 5 Rationale: Impaired or distorted muscle tone (dystonia) is a side effect of fluphenazine decanoate. Typical of dystonia are: spasms of the neck that pull the head to the side (torticollis; 2), and deviation and fixation of the eyes (oculogyric crisis; 5). Akathisia, the feeling of restlessness and an urgent need for movement, is not related to dystonia (1). Masklike facies and shuffling gait are symptoms of pseudoparkinsonism (4, 3).

Which client statement supports the diagnosis of somatic delusions? 1) "I wear this coat all the time to keep them from x-raying my organs." 2) "The president of France and I will be announcing our engagement soon." 3) "My heart stopped beating three days ago, and now my lungs are rotting away." 4) "The government has assigned a team of assassins to kill me because I know too much."

Answer: 3 Rationale: (3) SOMATIC delusions are a belief that the body is changing or behaving in an unusual way (e.g., the client's heart stopping and the lungs rotting away). (1?) CONTROL delusions center on the belief that others are attempting to control or affect the person in some manner. (2) EROTOMANIC delusions are focused on the belief that another person (usually famous or otherwise unattainable) is romantically interested in the client. (4) PERSECUTORY delusions involve beliefs that one is being singled out for harm.

A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing? 1) Echolalia 2) Hypochondriasis 3) Somatic delusions 4) Depersonalization

Answer: 3 Rationale: A SOMATIC DELUSION is a fixed false belief about one's body. ECHOLALIA is the automatic and meaningless repetition of another's words or phrases. HYPOCHONDRIASIS is a severe, morbid preoccupation with an unrealistic interpretation of real or imagined physical symptoms. DEPERSONALIZATION is a feeling of unreality and alienation from one's self.

What should the nurse assess first when evaluating memory impairment in a client with dementia? 1) Disorientation to self. 2) Recollection of past events. 3) Remembrance of recent events. 4) Impaired ability to name objects.

Answer: 3 Rationale: A common sign of dementia is the loss of memory of recent events. Disorientation of self is not a common sign of dementia; disorientation to time and place is more common. Recollection of past events is less impaired than that of recent events. Impaired ability to name objects is not as common as recent memory loss; if there are speech or language disturbances, this ability should be assessed.

Thomas is a 21-year-old male with a recent diagnosis of schizophrenia. Thomas's nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with: 1) Generally good health despite the mental illness. 2) An aversion to drinking fluids. 3) Anxiety and depression. 4) The ability to express his needs.

Answer: 3 Rationale: Anxiety, depression, and suicide co-occur frequently with schizophrenia. Patients with schizophrenia are also at greater best for poor health maintenance behaviors (1) and polydipsia (2). Alogia, a reduction in speech sometimes referred to as "poverty of speech," is a negative symptom of schizophrenia (4).

The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1) Ask direct questions to encourage talking. 2) Leave the client alone so as to minimize external stimuli. 3) Sit beside the client in silence with occasional open-ended questions. 4) Take the client into the day room with other clients so that they can help watch him.

Answer: 3 Rationale: Clients who are withdrawn maybe immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities with the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client safety is not the responsibility of other clients.

In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." What does the nurse conclude that the client is exhibiting? 1) Ideas of reference 2) Loose associations 3) Delusional thinking 4) Tactile hallucinations

Answer: 3 Rationale: DELUSIONS are false fixed beliefs that have a minimal basis in reality; this is a SOMATIC delusion. IDEAS OF REFERENCE are false beliefs that every statement or action of others relates to the individual. LOOSE ASSOCIATIONS are verbalizations that sound disjointed to the listener. TACTILE HALLUCINATIONS are false sensory perceptions of touch without external stimuli.

A client tells the nurse, "I'm a terrible, evil person. The voices are telling me that God needs to punish me." What is the most therapeutic initial response by the nurse? 1) "God is loving and won't punish you." 2) "Those voices you're hearing are a fantasy." 3) "Tell me what you're thinking about yourself." 4) "You aren't wicked -both God and I love you."

Answer: 3 Rationale: Encouraging the client to focus on the self will facilitate communication and foster self-perception. Stating that God will not punish the client denies the client's feelings and provides false reassurance. Stating that the voices are fantasy denies the client's experience. Stating that the client is not wicked denies the client's feelings and provides false reassurance.

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1) "I don't believe this is true." 2) "The guards are not out to kill you." 3) "Do you feel afraid that people are trying to hurt you?" 4) "What makes you think the guards were sent to hurt you?"

Answer: 3 Rationale: It is most therapeutic for the nurse to empathize with the client's experience (3). The remaining options lack this connection with the client (ie. disagreeing with the delusions may make the client more defensive, and the client may cling to the delusion even more; Encouraging discussion regarding the delusion is inappropriate.)

A client who sustained a head injury reports bland taste of food. Upon examination, the nurse finds that there is loss of taste perception from the anterior two-thirds region of the tongue. What is the origin of the involved nerve? 1) Medulla 2) Midbrain 3) Inferior pons 4) Cerebrum

Answer: 3 Rationale: Loss of taste perception from the anterior two-thirds of the tongue indicates injury to the facial nerve, which originates from the inferior pons. The medulla is the site of origin for the glossopharyngeal, vagus, accessory, and hypoglossal nerves. The optic nerve and oculomotor nerve originate from the midbrain. The site of origin for the olfactory nerve is olfactory bulb in the anterior ventral cerebrum.

A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for which finding? 1) Labored breathing 2) Edema of the neck 3) Difficulty swallowing 4) Alterations in BP

Answer: 3 Rationale: Muscles used for swallowing are innervated by the ninth (glossopharyngeal) and tenth (vagus) cranial nerves. Dyspnea is unrelated to cranial nerves; this is associated with neck edema and potential compromise of the airway. Edema of the neck will not influence the cranial nerves; some edema is expected because of the inflammatory process at the site of surgery. Alterations in blood pressure may occur but are not caused by cranial nerve dysfunction.

An 80-year-old client who lives at home has dementia of the Alzheimer type, stage 1. The client is irritable and forgetful. What conclusion should the home care nurse make regarding this client? 1) Must be supervised closely at all times 2) Needs a home health aide to assist with ADLs 3) Should be allowed to function independently if therapeutically possible 4) Ought to be responsible for carrying out daily self-care activities without assistance

Answer: 3 Rationale: Priority should be given to providing nursing care to Maintain an optimal level of safe function for as long as possible. Close supervision is usually not necessary during the early stages of dementia. Constant supervision can be destructive to self-esteem. A home health aide is usually not necessary during the early stages of dementia. The client may or may not be capable of performing all daily self-care activities.

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? 1) Ideas of grandeur 2) Confusing illusions 3) Persecutory delusions 4) Auditory hallucinations

Answer: 3 Rationale: The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.

A 20-year-old male patient diagnosed with chronic schizophrenia is placed on an antipsychotic, 20 mg twice a day. At the evening medication time, he expresses that he is not feeling well. The nurse assesses the patient and finds the following symptoms: oral temperature 103° F (39.4° C), pulse 110 beats/min, and respirations 24 breaths/min. The patient is diaphoretic and appears rigid. This patient is most likely suffering from which of the following? 1) Tardive dyskinesia 2) Pneumonia 3) Neuroleptic malignant syndrome 4) Pseudoparkinsonism

Answer: 3 Rationale: The symptoms are consistent with neuroleptic malignant syndrome, which is an adverse reaction to antipsychotic medication. While the other conditions listed in answers A and D may also be side effects of antipsychotic medication, the symptoms presented are not indicative of these conditions. Pneumonia may present with these vital signs; however, the diaphoresis and muscular rigidity are not.

Which therapeutic communication statement my psychiatric mental-health registered nurse used when a patient nursing diagnosis is "Altered Thought Process?" 1) "I know you say you hear voices, but I cannot hear them." 2) "Stop listening to the voices, they are not real." 3) "You say you hear voices, what are they telling you?" 4) "Please tell the voices to leave you alone for now."

Answer: 3 Rationale: When helping patients who are experiencing hallucinations, it is appropriate to inquire about the content of hallucinations and assess for command hallucinations (ie. hallucinations that direct a person to take an action; 3). While it is appropriate to address the underlying emotions, needs, or themes of a patient and promote reality testing, it is imperative NOT to negate the patient's experience (1, 2) or refer to hallucinations as real (4).

A client's parents ask about the treatment of their child who has a recent diagnosis of schizophrenia. Before responding, what should the nurse consider? 1) Electroconvulsive therapy is more effective in treating schizophrenia than mood disorders. 2) Family therapy has not been proved effective in the treatment of clients with schizophrenia. 3) Insight therapy has been proved highly successful in the treatment of clients with schizophrenia. 4) Drug therapy, although it does not eliminate the underlying problem, reduces the symptoms of acute schizophrenia.

Answer: 4 Rationale: (4) Psychoactive drugs have been shown to be capable of interrupting the ACUTE psychiatric process, making the client more amenable to other therapies. (1) Electroconvulsive therapy may be effective in treating depressed clients. (2) Family therapy is effective but is a long-term, costly proposition; signs and symptoms must be reduced before the client can participate. (3) Clients with schizophrenia usually have little insight into their problems; confronting the client through insight therapy will increase anxiety.

The nurse notes that a client has been experiencing a somatic delusion. Which statement led to this conclusion? 1) "I am Jesus Christ." 2) "I know I'm dead." 3) "This food has been poisoned." 4) "My stomach has disintegrated."

Answer: 4 Rationale: A SOMATIC delusion is a false belief that one has a disease or a physical defect. A GRANDIOSE is a belief that oneself is a person of importance. A NIHILISTIC delusion is a belief about death. A PARANOID delusion is a belief that others are out to cause personal harm.

When taking a health history from a client who has a moderate level of cognitive impairment as a result of dementia, what does the nurse expect to find? 1) Hypervigilance 2) Increased inhibition 3) Enhanced intelligence 4) Accentuated premorbid traits

Answer: 4 Rationale: A moderate level of cognitive impairment because of dementia is characterized by increasing dependence on environmental and social structure and by increasing psychological rigidity with accentuated previous traits and behaviors. Although paranoid attitudes, which are associated with hypervigilance, may be exhibited, the disorientation, loss of memory, and decrease in cognition usually do not lead to hypervigilance. With the decrease in impulse control that is associated with dementia, decreased, not increased, inhibition occurs. Enhancement of intelligence does not occur with dementia, but initially intellectual deterioration is subtle.

When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that: 1) Medications provided are ineffective. 2) Nurses are trying to control their minds. 3) The medications will make them sick. 4) They are not actually ill.

Answer: 4 Rationale: Anosognosia is the inability to realize that oneself is ill; this is caused by the illness itself.

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client? 1) Directing the client repeatedly to eat the food. 2) Explaining to the client the importance of eating. 3) Waiting and allowing the client to eat whenever the client is ready. 4) Having a staff member sit with the client in a quiet area during mealtimes.

Answer: 4 Rationale: By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions may help the client focus on eating. The client will not follow directions to eat because of the nature of the illness. Explaining the importance of eating and allowing the client to eat when ready are both unrealistic and will not ensure adequate intake.

A client paces back and forth across the floor, speaks incoherently, and continually talks to and verbally fights with people who are not present. What is the nurse's initial therapeutic intervention? 1) Setting limits on the client's verbal aggression. 2) Isolating the client to decrease the aggressive behavior. 3) Establishing a relationship to reduce the client's loneliness. 4) Providing emotional support while demonstrating acceptance of the client.

Answer: 4 Rationale: Clients who have lost contact with reality can be helped to reestablish contact with reality when the nurse demonstrates respect and focuses on the client; this distracts the client's attention from the hallucinations (4). This client is responding to voices, not reality; setting limits is reality oriented and is usually ineffective unless it involves directing the client to dismiss the voices (1). The client presents no immediate threat to the self or others; isolating the client will decrease contact with reality and will probably worsen the hallucinations (2). Although establishing a relationship may lessen the hallucinations, it takes a long time to do so, and the client needs immediate help (3).

A nurse is working in the orientation phase of a therapeutic relationship with a client who has borderline personality disorder. What will be most difficult for the client at this stage of the relationship? 1) Control and anxiety 2) Terminating the session on time 3) Accepting the psychiatric diagnosis 4) Setting mutual goals for the relationship

Answer: 4 Rationale: Clients with borderline personality disorder frequently demonstrate a pattern of unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals. Although the client with a borderline personality disorder may have difficulty in the areas of controlling anxiety, ending sessions on time, and accepting the diagnosis, none is the most significant issue.

A client is admitted to the hospital with the diagnosis of schizophrenia, undifferentiated type. The client sits rocking in a corner for long periods and responds to voices with words that the staff cannot understand. What should the nurse include when developing the plan of care for this client? 1) Including the client in a discussion group on the unit 2) Encouraging the client to talk to other clients during the day 3) Allowing the client to be alone while observing from a distance 4) Arranging the client's day to allow for short periods to be spent with the nurse

Answer: 4 Rationale: Clients with undifferentiated schizophrenia manifest psychotic signs and symptoms that preclude interaction with others for more than just short periods. They cannot function in a discussion group; psychotic manifestations such as fragmented delusions, vague hallucinations, disorientation, and incoherence prevent these clients from interacting with others. They have problems with interpersonal relations because their behavior is often bizarre and disorganized. Allowing the client to be alone will not relieve anxiety; instead, it will foster further withdrawal.

Which client condition is contraindicated for prescribing clozapine? 1) Seizures 2) Glaucoma 3) Dysrhythmias 4) Bone marrow depression

Answer: 4 Rationale: Clozapine is an atypical antipsychotic drug that is contraindicated in clients with bone marrow depression. Clozapine should be used with caution in clients with seizures.

A confused, hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse? 1) "May I examine your arms?" 2) "When did this feeling first start?" 3) "That's a rather unusual sensation." 4) "It can be frightening to feel that way."

Answer: 4 Rationale: Depersonalization communication is the result of a high anxiety level; projecting empathy to the client will facilitate exploration of concerns (4). The response "May I examine your arms?" does not acknowledge the frightening experience for the client and supports the client's hallucination (1). When the feeling started is irrelevant; the nurse must address what the client is experiencing now (2). The response "That's a rather unusual sensation" belittles the client's feelings and may make establishment of a therapeutic relationship difficult (3).

Gilbert, age 19, was described by his parents as a "moody child" with an onset of odd behavior at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered: 1) Favorable with medication. 2) In the relapse stage. 3) Improved with psychosocial interventions. 4) To have a less positive outcome.

Answer: 4 Rationale: Early assessment plays a key role in improving the prognosis for individuals with schizophrenia. Primary and secondary preventions include identification of symptoms, avoiding triggers (ie. stress, development of coping skills), supplemental essential fatty acids, and possible early treatment with antipsychotic medication.

A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms? 1) Her memory problems will likely decrease. 2) Depressive episodes should be less severe. 3) She will probably enjoy social interactions more. 4) She should experience a reduction in hallucinations.

Answer: 4 Rationale: First-generation antipsychotics affect (improve) positive symptoms, but have little effect on negative symptoms. 1, 2, and 3 refer to negative symptoms; 4 refers to the positive symptoms of schizophrenia.

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? 1) "Is your job demanding or stressful most of the time?" 2) "Do you participate in any strenuous sports activities on a regular basis?" 3) "Does anyone in your family have a history of central nervous system problems?" 4) "Were you aware of anything different or unusual just before your seizure began?"

Answer: 4 Rationale: Identification of a sensation that occurs before each seizure (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. An 'aura' is a complex of neurologic symptoms that proceed events, such as seizures and migraines; some people use the term 'aura' to describe the warning they feel before such an event.

A client who has a diagnosis of paranoid schizophrenia and has been violent in the past is admitted to the psychiatric unit. What should the nurse do before conducting an admission interview? 1) Move to the client's side and sit down. 2) Alert the assault response team about the client's history. 3) Have two other staff members present when talking with the client. 4) Enter the room with another staff member while remaining between the client and the door.

Answer: 4 Rationale: Making sure to stay between the client and the door provides safety for the nurse and the other staff member, because it will enable them to make a rapid exit. Moving to the client and sitting down invades the client's territory and may precipitate an aggressive client response. Alerting the assault response team is premature; the team is alerted when a client is out of control, harming self or others, and cannot be managed by the staff on the unit. Having two other staff members present may be viewed by the client as confrontational and may precipitate an aggressive response.

A nurse is caring for several clients with major thought disorders such as schizophrenia. They are all being treated with neuroleptic drugs. How do these drugs act in the body to promote mental health? 1) By inhibiting enzymes at the postsynaptic receptor site. 2) By decreasing serotonin at the postsynaptic receptor site. 3) By increasing dopamine uptake at the postsynaptic receptor site. By blocking access to dopamine receptors at the postsynaptic receptor site.

Answer: 4 Rationale: Neuroleptics block access to dopamine receptors, rather than inhibiting enzymes, at postsynaptic sites. They increase, not decrease, serotonin at postsynaptic sites.

Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? 1) Depersonalization. 2) Pressured speech. 3) Negative symptoms. 4) Paranoia.

Answer: 4 Rationale: Paranoia is an irrational fear, ranging from mild to profound. Fear may result in defensive actions, such as harming another person before that person can harm the patient.

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure? 1) Hypervigilance 2) Constricted pupils 3) Increased HR 4) Widening pulse pressure

Answer: 4 Rationale: Pressure on the vital centers in the brain causes an increase in the systolic blood pressure, WIDENING THE DIFFERENCE between the systolic and diastolic pressures. The client will be lethargic and have a lowered level of consciousness (ie. NOT hypervigilant). The pupils will be UNEQUAL or DILATED, not constricted. Pressure on the vital centers in the brain results in a DECREASED heart rate.

A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The healthcare provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client? 1) Physical therapy 2) Psychosocial support 3) Nutritional management 4) Antimicrobial administration

Answer: 4 Rationale: Preventing infection through the use of prophylactic antibiotics is the priority. Tearing the meninges may have introduced infectious organisms. Physical therapy is premature; physical therapy begun too early can increase ICP.

Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid? 1) Mydriasis 2) Bradycardia 3) Hypothermia 4) Circulatory collapse

Answer: 4 Rationale: The clinical symptoms of monoamine oxidase inhibitors (MAOIs) generally appears after 12 hours of ingestion. Circulatory collapse is associated with MAOI toxicity. Mydriasis, bradycardia, and hyperthermia are not associated with an isocarboxazid overdose.

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale? 1) Breathing patterns 2) Deep tendon reflexes 3) Eye accommodation to light 4) Motor response to verbal commands

Answer: 4 Rationale: The three areas of assessment to determine the level of consciousness using the Glasgow Coma Scale are: 1) motor response to verbal commands, 2) eye opening in response to speech, and 3) verbal response to speech. NOT assessed for the Glasgow Coma Scale: breathing patterns, deep tendon reflexes, and eye accommodation.

Name that Extra Pyramidal Side Effect (EPSE): A motor restlessness that causes pacing, repetitive movements, or an inability to stay still over mean in one place. It can be severe and distressing to patients and be mistaken for anxiety or agitation.

Answer: Akathisia Rationale: It is from Greek a-, meaning "not", and καθίζειν kathízein, meaning "to sit", or in other words an "inability to sit"

Definition. ______ : An inability to realize that one is ill, which is caused by the illness itself; prevalent in schizophrenia.

Answer: Anosognosia

A transient cognitive disorder caused by global dysfunction in cerebral metabolism resulting in altered cerebral function is _______.

Answer: Delirium Rationale: Delirium is a state of temporary but acute mental confusion, that is a life-threatening syndrome. The main contributing factor is impairment of cerebral oxidative metabolism, which means the brain gets less oxygen and has problems using it; multiple neurotransmitter abnormalities may be involved.

A neurocognitive disorder characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning is ______.

Answer: Dementia Rationale: Dementia has both treatable and untreatable underlying causes; however, prolonged exposure to the disease may result in irreversible changes. Causes of dementia include: Alzheimer's disease (60-80% of cases), vascular dementia (~20% of cases), dementia with Lewy bodies (10% of cases), and other (ie. frontotemporal lobular degeneration, Parkinson's disease, normal pressure hydrocephalus, Creutzfeldt-Jakob disease).

Name that Extra Pyramidal Side Effect (EPSE): a temporary group of symptoms that looks like Parkinson's disease: tremor, reduced accessory movements, gait impairment, reduced facial expressiveness, and slowing of motor behavior. For example: reduced arm swinging when walking, a fixed mask-like expression, and bradykinesia (ie. slowness of movement).

Answer: Pseudoparkinsonism

Name that Extra Pyramidal Side Effect (EPSE): A persistent EPSE involving involuntary rhythmic movements. The side effect usually begins in oral and facial muscles, and progress is to include the fingers, toes, neck, trunk, or pelvis.

Answer: Tardive Dyskinesia Rationale: tardive = late/delayed; dys = abnormal/ill; kinesia = movement

What scale is used as a standard assessment of neurological function?

Answer: The Glasgow Coma Scale Rationale: The Glasgow coma scale is used to establish baseline data in eye opening, motor response, and verbal response in acute care settings. According to the Glasgow coma scale: EYE OPENING (4 pts): spontaneous-4, to sound-3, to pain-2, never-1. MOTOR ANSWER (6 pts): obeys commands-6, localizes pain-5, normal flexion (withdrawal) -4, abnormal flexion-3, extension-2, none-1. VERBAL RESPONSE (5 pts): oriented-5, confused conversation-4, inappropriate words-3, incomprehensible sounds-2, none-1. The lower the score, the lower the client's neurological function.

First-generation antipsychotics are dopamine D2 ______, which _____ D2 receptors.

Answer: antagonists, block

First-generation antipsychotic drugs are also known as ______ antipsychotics.

Answer: typical/conventional Rationale: First-generation antipsychotic drugs are also known as typical antipsychotic, while second-generation antipsychotics are also known as atypical antipsychotics.

______ is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands.

Answer: Psychosis

A nurse is caring for a client with a tumor of the cerebellum. What clinical manifestation does the nurse expect the client to exhibit? 1) Absence of the knee jerk reflex 2) Change in level of consciousness 3) Inability to execute voluntary movements 4) Inability to execute coordinated movements

Answer: 4 Rationale: The cerebellum is involved in the synergistic control of muscle action. Below the level of consciousness, it functions to produce smooth, steady, coordinated, and efficient movements. The brain is not involved in a simple reflex arc. The cerebrum is responsible for the level of consciousness and voluntary motor function.

To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply. 1) Alcohol use disorder. 2) Major depressive disorder. 3) Stomach cancer. 4) Polydipsia. 5) Metabolic syndrome.

Answer: 1, 2, 4, 5 Rationale: Comorbidities of schizophrenia include alcohol use disorder, depression, and polydipsia (ie. compulsive drinking of excess fluids). Side effects second-generation antipsychotics include metabolic syndrome.

A 3-month-old infant has a ventriculoperitoneal shunt inserted. What should the nurse include in the infant's plan of care? 1) Keeping the infant in the prone position 2) Applying moist sterile dressings to the incision 3) Watching for signs of cerebral fluid leakage 4) Teaching the parents signs of increased ICP

Answer: 4 Rationale: The parents must be taught to identify signs of increased intracranial pressure, because this condition may develop if shunt malfunction occurs; immediate intervention is essential. The prone position places too much pressure on the shunt; the infant should be positioned flat and turned on the unaffected side. Dry sterile dressings are applied after surgery to prevent infection. Cerebrospinal fluid is not expected to drain from the incision.

_____ are spasms of the neck that pull the head to the side; this is typical of dystonia.

Answer: Torticollis