Exam 3 Study Quide

Individuals diagnosed with schizophrenia display varying degrees of neurocognitive impairments that are evidenced by what factors?

Disorganized thinking and speech. Rationale: Individuals diagnosed with schizophrenia display varying degrees of neurocognitive impairments, including disorganized thinking and disorganized speech. Psychosis is a symptom that refers to the total inability to recognize reality. Substance abuse occurs in more the 50 percent of individuals with schizophrenia, but it is not a neurocognitive impairment. Disorganized personality is not a recognized symptom.

The client treated with lithium carbonate repeatedly requests water to drink and has slurred speech. What is the priority nursing action in this case?

Evaluate the client's blood lithium level. Rationale: Excessive thirst, slurred speech, and polyuria are early signs of lithium toxicity. The nurse should frequently check the client's lithium level. Food does not help prevent lithium toxicity. Mannitol can be administered to eliminate the drug if severe toxicity is determined, but it must be diagnosed first. The nurse can report to the primary health care provider after checking the lithium levels in the blood.

A client diagnosed with bipolar disorder takes lithium. After playing soccer on a hot summer day, the client complains of nausea, vomiting, diarrhea, and thirst. The client's hands begin to tremble, and the gait becomes unsteady. Which are priority nursing interventions?

Instruct the client not to take any more lithium until directed by the health care provider and collaborate with the health care provider about drawing a serum lithium level immediately. Rationale: The client likely became dehydrated by the high activity in the summer heat, potentially causing lithium toxicity. The lithium must be restricted, and a serum lithium level needs to be drawn. An antiemetic medication may be helpful to the client, but it should only be given after the lithium level has been tested. An AIMS assessment applies to potential adverse effects of antipsychotic medications and does not need to be conducted. If lithium toxicity is suspected, no additional lithium should be given.

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" What does this cognitive distortion represent?

Learned helplessness. Rationale: Learned helplessness results in depression when the client feels no control over the outcome of a situation. Self-blame is an example of negative self-appraisal wherein the client believes that everything is his or her fault. Catatonia is abnormal physical movement. Discounting positive attributes occurs when clients are unable to recognize what they do well.

A nurse administers medications to four clients with Alzheimer disease. Which medication would be expected to interfere with glutamate rather than cholinesterase?

Memantine. Rationale: Memantine blocks the effects of excess glutamate and is used in moderate to late stages of Alzheimer disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are used most often to treat mild to moderate Alzheimer disease.

A client is prescribed tricyclic antidepressants. What should the nurse check for in the client's case history before administering the drug?

Oral contraceptive use. Rationale: Medications such as oral contraceptives, antihypertensive reagents, monoamine oxidase inhibitors, and anticoagulants may react with tricyclic antidepressants. Potent side effects can occur due to drug interaction. The nurse should check for administration in the client's case history and inform the primary healthcare provider. Suicidal ideation, loss of appetite, and insomnia are common symptoms of depression.

Which is an acute-phase nursing intervention aimed at reducing hyperactivity for a client experiencing mania?

Redirect the client to write in a diary. Rationale: Effective interventions offer reduction of environmental stimulation and solitary, noncompetitive activities. Writing in a diary meets these requirements. Exercising in the gym will likely be too stimulating for the hyperactive client. Leading unit activities and orienting a new client to the unit are not solitary activities and will not give the client a good opportunity for success.

Three months after the death of his wife, an 86-year-old man begins having difficulty with concentration and sleep. Family members must provide reminders and encouragement for him to bathe, take prescribed medications, and eat regularly. Which nursing action is most appropriate?

Refer this client for further evaluation and treatment of suspected depression. Rationale: This client experienced a serious loss; signs of depression are evident. Further evaluation and treatment is needed. Depression in the older adult is frequently confused with dementia. The scenario does not suggest that the client has dementia or needs placement in a skilled care facility. A hypnotic medication is likely to increase this client's confusion.

The nurse has developed a plan for a client with a severe sleep pattern disturbance to spend 20 minutes in the gym exercising each afternoon. Which intervention should be scheduled upon returning to the unit?

Rest. Rationale: A depressed client usually has little energy. After even a short exercise period, the client may feel exhausted and need rest. Group therapy could be counterproductive to this need, while a protein-based snack and unstructured private time may not directly address it.

A client diagnosed with Alzheimer disease has become more forgetful and has difficulty performing familiar tasks like bathing and dressing. The nurse would assess the client as being in which stage of Alzheimer disease?

Stage 3, moderate-severe. Rationale: Moderate-severe Alzheimer disease is marked by ambulatory dementia and requires a high level of supervision. Wandering and inability to meet self-care needs become problematic. Stage 1 is marked by short-term memory loss. Stage 2 is marked by increasing confusion. Stage 4 is marked by immobility and the inability to recognize family and self.

The nurse is assessing a client with dementia. What problem does the nurse document as related to apathy?

The client engages in little conversation. Rationale: If the client engages in little conversation, the nurse identifies and documents it as a problem of apathy. Wandering out of the house indicates risks to the client at home. Losing things indicates memory impairment. If the client loses his or her way around the house, it is documented as disorientation.

A nurse begins a therapeutic relationship with a client diagnosed with schizophrenia. The client has severe paranoia. Which comment by the nurse is most appropriate?

"As you get to know me better, I hope you will feel comfortable talking to me." Rationale: The nurse's statement that he or she hopes the client will become comfortable talking with him or her as the client is most appropriate. It addresses the client in a nonthreatening way. Asking someone with severe paranoia to make goals for him or herself could stimulate an increase in paranoid thinking. Directly addressing the client's problem with fear and suspicion will likely only increase the client's fear and suspicion, so this is not the most appropriate comment. Indicating that the nurse is personally a part of the treatment plan acts contrary to the best practice of avoiding placing the client-caregiver relationship at the center of the conversation, so this is not the most appropriate statement either.

Which child or teenager is demonstrating classic depression-related behavior?

A 4-year-old cries frequently for no apparent physical reason, an 8-year-old consistently declines offers to play with schoolmates, and a 15-year-old becomes verbally abusive to siblings. Rationale: As children grow and develop, they may display a wide range of moods and behaviors, making it easy to overlook signs of depression. For example, a very young child may cry, a school-age child might withdraw from schoolmates, and a teenager may become irritable with siblings in response to feeling sad or hopeless. The 6-year-old who demands to sleep with one parent when the other is away and an 11-year-old who cries when a beloved family pet runs away are examples of acute grief or anxiety rather that depression.

A client diagnosed with schizophrenia says to the nurse, "I do not need any treatment because there is nothing wrong with me, I am perfectly fine." The nurse recognizes that the client is experiencing what symptom?

Anosognosia. Rationale: Clients diagnosed with schizophrenia often don't believe that they are ill, which leads to complications in treatment. Anosognosia is the inability for a person to recognize that he or she has an illness because of the illness itself. Delusions and hallucinations are elements of a psychotic state in which the client has the inability to recognize reality and experiences alterations in perception. Disorganized thinking is a neurocognitive aspect of schizophrenia.

A client diagnosed with schizophrenia complains to the nurse about persistent feelings of restlessness and says, "I feel like I need to move all the time." What is the nurse's next action?

Assess the client for other extrapyramidal symptoms. Rationale: The nurse should assess the client for other extrapyramidal symptoms. Restlessness (akathisia) is a common extrapyramidal symptom. Adding activity to the client's plan of care could benefit the client but will not address the potential extrapyramidal symptoms, so this action can come later. Performing a full mental status evaluation of the client is unnecessary, because the client had been diagnosed with schizophrenia and is already discussing specific issues that the nurse can directly evaluate. Educating the client about psychomotor agitation is not relevant to the client's feelings of restlessness, because this is typically an issue for people experiencing catatonia.

Which nursing intervention would be most appropriate for an older individual suspected of being at risk for the development of the unique symptoms of delirium?

Assessing orientation to person, place, and time every 2 hours. Rationale: Delirium reduces awareness of the environment that involves sensory misperceptions and disordered thought (disturbed attention, memory, thinking, and orientation) and also disturbances of psychomotor activity and the sleep-wake cycle. These disturbances develop rapidly (over hours to days). Frequent assessment of an individual at risk for developing delirium for orientation would be most appropriate. Assuring ambulation, cutting food into small pieces, and assuring warm clothing are appropriate but not needs unique to an individual at risk for developing delirium.

What is the most common type of hallucination in schizophrenia?

Auditory. Rationale: Auditory hallucinations are the most common type of hallucination in schizophrenia. Tactile hallucinations are common in cocaine, amphetamine, and alcohol withdrawal. Visual hallucinations are more probable in delirium or dementia. Gustatory is the rarest type of hallucination.

A client diagnosed with schizophrenia is most likely to experience which type of hallucination?

Auditory. Rationale: Clients diagnosed with schizophrenia may experience hallucinations arising out of any of the senses; however, 60 percent of people with schizophrenia experience auditory hallucinations at some time during their lives. Visual hallucinations are more commonly associated with substance abuse and withdrawal. Tactile and olfactory hallucinations are rare.

A client who is manic with rapid cycling manic symptoms is treated with carbamazepine. Which adverse effect should the nurse report to the health care provider for a client who is on continuous administration of this drug?

Bone marrow suppression. Rationale: Carbamazepine is an anticonvulsive drug. With continuous administration, it can cause bone marrow suppression and liver inflammation due to an increase in liver enzymes. Seizures, severe hypotension, and changes in a client's electroencephalograph are caused by increased levels of lithium in the blood, more than or equal to 1.5 mEq/L, not continuous administration of carbamazepine.

Which body system is most at risk for decompensation during the acute phase of a severe manic episode?

Cardiac. Rationale: A primary consideration for a client in acute mania is the prevention of exhaustion and death from cardiac collapse. Because exhaustion due to mania is life-threatening, a careful cardiac assessment takes priority over renal, endocrine, and pulmonary systems.

A client with Alzheimer disease tends to wander at night. What appropriate measures does the nurse follow to ensure client safety?

The nurse makes the client wear a bright vest. Rationale: The client who tends to wander at night must be given a bright vest to wear. Name, address, and telephone number must be written on the vest so that the person can be easily identified. The client should not be secluded, which may lead to agitation and anxiety in the client. The throw rug should be removed from the client's way so it does not cause the client to trip and fall. The client may fall due to confusion, so mattresses must be kept on the floor to avoid injury.

Which complaint regarding sleep would the nurse expect from a client diagnosed with major depression?

"I wake up about 4 AM and cannot go back to sleep. I feel tired all the time." Rationale: Change in sleep patterns is a cardinal sign of depression. Often, people experience insomnia, wake frequently, and have a total reduction in sleep, especially deep-stage sleep. One of the hallmark symptoms of depression is waking at 3 or 4 AM and then staying awake or sleeping for only short periods. Napping and vivid dreams are normal sleep variations. Falling asleep in the middle of an activity is indicative of narcolepsy.

Which statement made by the client demonstrates an understanding of the benefit of clozapine?

"I'm less likely to develop a stooped, shuffling walk." Rationale: Clozapine is an example of second-generation antipsychotic (SGA/atypical medication. The atypical second-generation antipsychotics (SGAs) have fewer disturbing extrapyramidal side effects (EPS). However, the SGAs in general have a higher risk for metabolic syndrome (weight gain, diabetes, and dyslipidemia) than the first-generation antipsychotics. As well, the SGAs lead to more cardiovascular events and premature deaths than the first-generation antipsychotics. The SGAs are also considerably more expensive than the more traditional first generation antipsychotics (FGAs).

A client diagnosed with bipolar disorder has taken lithium for 1 year with good results. Today, the client phones the nurse with multiple complaints. Which complaint should receive the nurse's priority attention?

"I've had bad diarrhea for 3 days." Rationale: Diarrhea makes this client vulnerable to dehydration, which can result in increased concentration of lithium in the blood. This increased drug concentration can lead to lithium toxicity, a dangerous condition for which the nurse should monitor the patient. Fine tremors and weight gain are expected side effects associated with lithium therapy. The nurse should be sensitive to these concerns, but they are not a priority. Salt is important for patients who take lithium, so it is acceptable that the client is putting a little extra salt on meals.

A client diagnosed with bipolar disorder has taken lamotrigine for 3 months with good results. Today, the client calls the nurse with multiple complaints. Which complaint should receive the nurse's priority attention?

"I've noticed a new rash on my chest and abdomen." Rationale: Lamotrigine is a first-line treatment for bipolar depression and is approved for acute and maintenance therapy. Lamotrigine is generally tolerated well, but there is one serious but rare dermatological reaction: Stevens-Johnson Syndrome, a potentially life-threatening rash. Most rashes are likely benign, but clients should be instructed to seek immediate medical attention if a rash appears. Sleeping for 7½ hours is healthy. Two days without a bowel movement does not necessarily represent constipation. A bruise is a normal result from a minor trauma.

Which client statements support the diagnosis of mania?

"I've telephoned everyone I know and talked for hours." "I really don't need much sleep; 2 hours a night is enough." "My friends all say this outfit is way too sexy, but I like it and wear it all the time." "My family is really upset with me, but it's just because they're jealous of everything I do." Rationale: When in the height of mania, a person constantly goes from one activity, place, or project to another with little or no regard for sleep or food. Incessant talking is indicative of a manic episode. Inactivity is impossible, even for the shortest period of time. Behaviors and actions during manic episodes often alienate the client's family and friends. Dress may be described as outlandish, bizarre, colorful, and noticeably inappropriate. The statement regarding cooking and eating does not indicate manic behavior.

A client has taken citalopram for 2 years for dysthymic disorder. The client's outcomes have been achieved, and the client wants to discontinue the medication. Which information should the nurse provide to the client?

"It's important for you to gradually stop taking this drug, over 2 to 4 weeks." Rationale: Selective serotonin reuptake inhibitor (SSRI) medications should not be discontinued abruptly. Abrupt cessation can lead to serotonin withdrawal. The duration of treatment with citalopram is individualized based on the client's symptoms and is usually not lifelong. Alleviation of symptoms is not necessarily an indication that medication may be discontinued. Neuroleptic malignant syndrome is an adverse effect associated with use of antipsychotic medications, not SSRIs.

A community mental health nurse counsels a group of clients about the upcoming flu season. What instruction does the nurse provide for clients who are prescribed lithium?

"Stop taking your medicine, and contact me if you develop nausea, vomiting, and/or diarrhea." Rationale: Nausea, vomiting, and diarrhea can all be early signs of lithium toxicity, so the nurse should advise clients to contact him or her if this occurs. Clients taking lithium are not more likely to experience unique symptoms from the flu. Clients taking lithium are not more vulnerable to catching the flu. Because the flu is contagious, anyone who develops it should be isolated from others.

A client was diagnosed with bipolar disorder many years ago. The client tells the nurse, "When I have a manic episode, there's always a feeling of gloom behind it, and I know I will soon be totally depressed." What is the nurse's most appropriate response?

"Your comment indicates you have an understanding and insight about your disorder." Rationale: Clients diagnosed with bipolar disorder often experience depression during and after a manic episode. The correct response is therapeutic communication because it reflects the client's understanding of the disorder. It is possible that many people diagnosed with bipolar disorder do experience the stated feeling, but this response does not address the client in a way that helps him or her feel empowered to express him or herself. Explaining where depression can come from does not address the client's concern or his or her insight, so this is not the best response. Even with a prescription, feelings of gloom may occur, so the implication that the client should not have that experience if he or she takes his or her medication as described is unhelpful and inaccurate.

Which newly hospitalized client does the nurse least need to monitor closely for development of delirium?

72-year-old who says, "I have one glass of wine every evening to stimulate my appetite." Rationale: Someone who has one glass of wine per day would not be expected to experience withdrawal and therefore does not need close monitoring for the onset of delirium. The 48-year-old who usually drinks a six pack of beer should be monitored for the development of delirium because of the risks associated with alcohol withdrawal. Someone who has a history of thiamine deficiency is at risk for delirium and should be monitored. The 78-year-old diabetic whose blood glucose levels are greater than 250 mg/dL is at some risk for delirium due to his or her age and diabetes, and should be monitored for delirium.

Based on current research, which client is most likely to develop dementia?

A former boxer who is now a trainer. Rationale: Brain injury and trauma are associated with a greater risk of developing Alzheimer disease and other dementias. People who suffer repeated head trauma, such as boxers and football players, may be at greater risk. Office managers, factory workers, and bartenders do not necessarily have a higher risk.

A client who exhibits concrete thinking is unable to communicate in what manner?

Abstractly. Rationale: Concrete thinking refers to an over emphasis on specific details and impairment in the ability to use abstract thinking. The client is able to communicate coherently and reasonably. Positive communication is not a concept hindered by concrete thinking.

A client diagnosed with bipolar disorder is in the continuation phase of treatment. Which of the following outcomes most applies to this phase?

Accurately stating indicators of relapse. Rationale: The overall outcome of the continuation phase is relapse prevention. Interventions include psychoeducation for the client and family focused on knowledge of the disease process and medication, consequences of substance addictions, knowledge of early signs and symptoms of relapse, support groups or therapy, and communication or problem-solving skills training. A labile mood is not a desirable outcome. Getting sufficient sleep and rest and demonstrating thought self-control are outcomes that better apply to the acute phase of treatment.

In what phase in the course of schizophrenia does the client experience hallucinations and flat affect?

Acute phase. Rationale: During the acute phase, the client experiences hallucinations and flat affect. The maintenance phase occurs when symptoms are in remission. In the stabilization phase, acute symptoms, particularly the positive symptoms, decrease in severity. The prodromal phase occurs when the signs and symptoms precede the acute, fully manifested signs and symptoms of the disease.

A depressive client is prescribed tricyclic antidepressants. What appropriate advice does the nurse give to the client's family?

Advise the client to be cautious while driving. Rationale: Tricyclic antidepressants (TCAs) cause side effects such as drowsiness or dizziness. The client must be advised to be cautious while crossing the road, driving, or working with machines. The client must take a full dose at bedtime, so that the side effects are less during the day. If the client forgets to take the dose, the next dose should be taken at the scheduled time. A double dose should be avoided. The medication should not be stopped if there is reduction in blood pressure, because medication cessation can cause nausea, altered heartbeat, cold sweats, and nightmares.

The health care provider mentions to the nurse that a client who is about to be admitted has sundown syndrome. What can the nurse expect to observe nightly?

Agitation. Rationale: Sundown syndrome involves increased disorientation and agitation occurring at night. It is not directly related to lethargy, depression, or mania.

A client diagnosed with Alzheimer disease looks confused when the phone rings and cannot recall many common household objects by name. What term will the nurse use to document this loss of function?

Agnosia. Rationale: Agnosia is loss of the ability to recognize familiar objects. Apraxia is the loss of purposeful movement. Aphasia is the loss of language ability. Anhedonia is the inability to feel pleasure.

A client diagnosed with Alzheimer disease picks up his or her glasses from the bedside table but does not recognize what they are or their purpose. The nurse will document this behavior using which term?

Agnosia. Rationale: Agnosia is the loss of sensory ability to recognize objects. Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. Aphasia is the loss of language ability. Agraphia is the loss of the ability to read or write.

A client says to the nurse, "I once enjoyed going to parks and museums with my family but that is not fun anymore." How would the nurse document this complaint?

Anhedonia. Rationale: Anhedonia means that there is no pleasure or joy in life. It is a common finding with depression. Anergia refers to a lack of energy or physical passivity. Euthymia refers to a mood state that is normal and moderate, with neither depression nor mania. Self-deprecation refers to negative statements about self.

Which strategies will the nurse implement when caring for a client who is experiencing auditory hallucinations?

Call the client by name, speak loud enough to attract the client's attention, work to maintain eye contact with the client, and assess for suicidal or homicidal commands. Rationale: When a client is hallucinating, the nurse focuses on understanding the client's experiences and responses. Suicidal or homicidal themes or commands necessitate appropriate safety measures. Calling the client by name, speaking simply and loudly enough to be understood amid the hallucinations, and maintaining eye contact help the nurse present as nonthreatening and nonjudgmental to the client as the nurse assesses him or her for suicidal or homicidal commands. Removing the client to seclusion is not always necessary and is implemented only when there are reasons to believe the client poses harm to himself or herself or to others.

The nurse is teaching the family caregivers how to communicate with a client who has dementia. What communication strategy can improve orientation of the client?

Call the person by name every time you see him or her. Rationale: In dementia, the short-term memory of the client is impaired and requires frequent orientation. The nurse should teach family members to regularly call the client by name. Face-to-face eye contact is important to allow the client to use both verbal and nonverbal clues for better understanding. When the client is aggressive, the family members should acknowledge the client's feelings and change the topic. Acknowledging the client's feelings makes him or her feel better understood. It may be helpful to remind the client about past accomplishments to distract the client from deficits in his or her present life and give meaning to his or her existence.

Which assessment finding regarding communication is likely in a client experiencing acute mania?

Clang associations. Rationale: Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning. This communication style occurs commonly in clients experiencing mania. Mutism, poverty of ideas, and psychomotor retardation are assessment findings usually associated with depression rather than mania.

What is the overall goal for clients diagnosed with schizophrenia during the acute phase?

Client safety and medical stabilization. Rationale: The overall goals for a client diagnosed with schizophrenia during the acute phase are client safety and medical stabilization. Relapse prevention, adherence to medication regimens, and understanding the disease occur during stabilization and maintenance.

A client with schizophrenia has been prescribed a second-generation antipsychotic medication for management of symptoms. Which conditions are expected to improve as a result of medication therapy adherence?

Cognition and delusions. Rationale: Cognition and delusions are expected to improve as a result of second-generation antipsychotic medication adherence. Weight gain and hypertension are two side effects of the medication that are expected to emerge or worsen if the client already has issues with those conditions. Also, self-esteem can worsen because of weight gain and lead to adherence problems.

The nurse can most expect a client demonstrating typical manic behavior to be attired in what type of clothing?

Colorful and outlandish. Rationale: Manic patients often manage to dress and apply makeup in ways that create a colorful, sometimes bizarre, appearance. They do not tend to dress modestly and are not compulsively neat. Manic patients are not generally ragged in appearance; rather, they choose loud colors and mismatched patterns.

A client diagnosed with bipolar disorder was hospitalized 15 days ago and has been receiving lithium. Current assessment findings include increased restlessness, pressured speech, and flight of ideas. The client sleeps 2 hours per night. What is the nurse's most appropriate intervention?

Consider the need to obtain a lithium level from the laboratory. The client may not be swallowing the medication. Rationale: Lithium must reach therapeutic levels in the client's blood to be effective; this usually takes 5 to 14 days. In this scenario, the assessment findings indicate continued mania; the nurse should therefore question whether the client actually has been taking the medication, and only a serum lithium level test can provide definitive results. The client has taken lithium long enough to not be seeing therapeutic effects; continuing to monitor the client's symptoms is an inadequate response. This client will be unable to practice concentration because of continuing flight of ideas. The client needs therapeutic intervention; excluding group therapies denies the client's right to treatment.

Which nursing diagnosis would be most useful for a depressed client who shows psychomotor retardation?

Constipation. Rationale: A client with psychomotor retardation has vegetative signs of depression and often is constipated. Depressed clients usually do not have death anxiety. They are more likely to welcome the idea of dying. Diarrhea is more likely to occur with psychomotor agitation. When imbalanced nutrition occurs, clients are more likely to have less than body requirements.

The family members of a client with stage 2 Alzheimer disease have jobs and cannot provide adequate supervision for the client. What is a reasonable alternative for the nurse to explore with them?

Day care. Rationale: Day care is a good option for clients with moderate Alzheimer disease. It provides supervision, a protected environment, and supportive interactions. This client is unlikely to require acute care hospitalization, long-term institutionalization, or group home residency at this stage.

A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning is confused and disoriented. What condition does the nurse suspect?

Delirium. Rationale: Delirium is characterized by a disturbance of consciousness, a change in cognition (such as impaired attention span), and a fluctuating level of consciousness that develops over a short period of time. Dementia progresses slowly, over months to years. Depression and caregiver role strain are not associated with confusion and disorientation developing overnight.

Dementia in an older adult is often a misdiagnosis for what condition?

Depression. Rationale: Depression in an older adult frequently is confused with dementia. Dementia is typically not misdiagnosed as cerebral emboli or poor nutritional status, which can be confirmed via physical assessment and diagnostic testing. Symptoms of dementia are often more severe than normal effects of aging.

Which statements are true regarding serotonin syndrome?

Discontinue all selective serotonin reuptake inhibitors (SSRIs) for 2 to 5 weeks before starting a monoamine oxidase inhibitor (MAOI), symptoms include hypertension and delirium, and death can result from severe symptomology. Rationale: A client should discontinue all SSRIs for 2 to 5 weeks before starting an MAOI. Symptoms of serotonin syndrome include hypertension and delirium, as well as abdominal pain, diarrhea, sweating, fever, tachycardia, myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change. Severe manifestations can induce hyperpyrexia (excessively high fever), cardiovascular shock, or death. Serotonin syndrome is thought to be related to overactivation of the central serotonin receptors caused by either too high a dose or interaction with other drugs. Hypothermia and septic shock are not directly associated with serotonin syndrome.

Which behaviors are characteristic of the manic phase of bipolar disorder?

Excessive energy, pressured speech, racing thoughts, and purposeless movement. Rationale: Excessive energy, pressured speech, purposeless movement, and racing thoughts are typical of mania. Fatigue and increased sleep and low self-esteem are more characteristic of depression.

A client who is bipolar tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those television concerts are going to retire because they can't compete with me." What does the nurse document?

Grandiosity. Rationale: Exaggerated beliefs in one's own importance, identity, or capabilities is considered grandiosity. Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes among topics. Distractibility describes attention being too easily drawn to unimportant or irrelevant external stimuli. Limit testing describes a person's pushing the limits of what behavior is acceptable.

A client admitted with acute mania tells the staff and the other clients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. The client states "I am the only one he trusts, because I am the best!" For documentation purposes, which term describes this behavior?

Grandiosity. Rationale: Grandiosity is inflated self-regard. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. Although patients with mania are unpredictable, this scenario does not describe unpredictability. Rapid cycling is switching between mania and depression in a given time period. The scenario does not describe flight of ideas, which involves a continuous flow of speech with abrupt topic changes.

The client in the dining room states, "I am not eating this food; it tastes like someone has poisoned it." What type of hallucination is this client experiencing?

Gustatory. Rationale: This client is experiencing gustatory hallucinations. Gustatory hallucinations are tasting sensations that are not present in the environment. Olfactory hallucinations involve smelling odors that are not in the environment. Auditory hallucinations entail hearing voices or sounds that do not exist in the environment, but are projections of inner thoughts or feelings. Seeing persons, objects, or animals that are not in the environment is visual hallucination.

The nurse is assessing a client suspected of having Alzheimer disease (AD). What action by the client does the nurse identify as a sign of agnosia?

Has difficulty identifying familiar sounds like the ring of the telephone. Rationale: When the client is unable to identify the ring of the telephone, there is loss of sensory ability to recognize familiar sounds. The nurse recognizes it as a feature of auditory agnosia. If the client babbles and speaks incoherently, there is loss of language ability. The nurse identifies this as a sign of aphasia. In AD, there is gradual deterioration of recent and remote memory. A client who is unable to recall what was served for breakfast an hour ago is showing signs of impairment of recent memory. Clients with AD often confabulate in an unconscious attempt to maintain self-esteem. An example of confabulation would be talking about how the President's decision was directly influenced by the client.

What assessment data are primary risk factors for depression?

History of physical abuse as a child and alcohol abuse. Rationale: Primary risk factors of depression include early childhood trauma and history of alcohol or other substance abuse. Female gender, low socioeconomic class, and unmarried are other primary risk factors.

Which assessment data support the suspicion that a depressed client is demonstrating self-directed anger?

Hospitalized for alcohol detoxification, diagnosed as being morbidly obese, and three-pack-a-day cigarette smoker. Rationale: Anger in depression may be directed toward the self in the form of suicidal or otherwise self-destructive behaviors (e.g., alcohol abuse, substance abuse, overeating, smoking, etc.). Multiple marriages and financial problems are not characteristic examples of self-directed anger.

What is an expected finding in a client displaying associative looseness?

Illogical thinking. Rationale: The expected findings in a client displaying associative looseness include illogical thinking. Clang associations are the meaningless rhyming of words. A neologism is a made-up word that has special meaning to the client. Mimicking movements of another is known as echopraxia.

A 72-year-old client hospitalized with pneumonia and experiencing delirium points to the intravenous (IV) pole and screams, "Get him out of here! He's going to hurt me!" What term is used to describe the reaction the client is having?

Illusion. Rationale: Illusions are errors in perception of sensory stimuli. The stimulus is a real object in the environment that is misinterpreted and often becomes the object of the projected fear. Hallucinations are false sensory stimuli. For example, individuals experiencing delirium may become terrified when they "see" giant spiders crawling over the bedclothes or "feel" bugs crawling on or under their bodies. A delusion is described as thinking or believing something that is not true and is seen more often in schizophrenia. For example, a client may firmly believe that government agencies can read and are monitoring his or her thoughts or that neighbors can see him or her through walls. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem.

A client diagnosed with delirium insists that a vacuum hose is a large, poisonous snake. What term will the nurse use to describe what the client is demonstrating?

Illusions. Rationale: Illusions are errors in the perception of a sensory stimulus. Hallucinations are false sensory stimuli. Hypervigilance is an elevated level of alertness that may be associated with disorientation and agitation. Agnosia is loss of the sensory ability to recognize objects.

A pregnant client is diagnosed with seasonal affective disorder. What appropriate action does the nurse include in the client's treatment plan?

Instruct the client to get exposed to a light source for 30 to 45 minutes daily. Rationale: Light therapy is the best treatment for seasonal affective disorder. It increases the melatonin secretion by the pineal gland. It is ideal to expose the client to a light source for 30 to 45 minutes. St. John's wort (Hypericum perforatum) should not be given to pregnant clients, because it may not be safe. Selective serotonin reuptake inhibitors must not be used in pregnant clients, because they may have teratogenic effects on the fetus. Exercise enhances mood, so the nurse should not discourage the client from exercising.

Which statements regarding therapy with lithium are true?

It demonstrates effectiveness in the treatment of bipolar I, manic behaviors generally show improvement in 10 to 21 days, and indeterminate maintenance dosing is required for many clients. Rationale: Lithium carbonate is effective in the treatment of bipolar I acute and recurrent manic and depressive episodes. It inhibits about 80 percent of acute manic and hypomanic episodes within 10 to 21 days. Many clients receive lithium for maintenance indefinitely and experience manic and depressive episodes if the drug is discontinued. Lithium is less effective in those with rapid cycling. It can help reduce hypersexuality but to a lesser degree than other symptomology.

What information concerning electroconvulsive therapy (ECT) treatment and its effectiveness for clients diagnosed with bipolar disorder is true?

It is promising for clients with a history of rapid cycling. Rationale: ECT is used to subdue severe manic behavior, especially in clients with treatment-resistant mania and clients with rapid cycling. It is not necessarily useful for all cases of mania. Depressive episodes, particularly those with severe, catatonic, or treatment-resistant depression, are an indication, not contraindication, for this treatment. ECT is effective for clients with bipolar disorder who have rapid cycling, and for those with paranoid-destructive features.

The nurse is caring for a client with Alzheimer disease who tends to get frightened and cry out at night. What nursing intervention is most appropriate for this client?

Keep the area well lit at night. Rationale: Clients with Alzheimer disease can get frightened, awaken, or cry out at night. Hence, the area must be kept well lit to reinforce orientation and minimize possible illusions. Restraints should not be used because the client may become more terrified, fight against the restraint, and become dangerously exhausted. The intake of food and fluids is monitored when the client is anorexic or too confused to eat. Barbiturates should not be given, because they have a paradoxical reaction, causing agitation.

What should the nurse monitor in clients who have bipolar disorder and have been administered divalproex sodium?

Live function and platelet count. Rationale: The nurse should monitor platelet count and liver function in clients who are prescribed divalproex sodium. This drug can cause liver dysfunction by altering the levels of liver enzymes and can cause thrombocytopenia by decreasing the platelet count. Blood pressure does not need to be monitored in these clients, because divalproex sodium does not affect blood pressure. Skin rashes are not typically caused by divalproex sodium, though they can occur in clients who are prescribed lamotrigine. Divalproex sodium does not cause impairment of pancreatic function, nor does it affect levels of insulin and glucagon; thus, pancreatic function does need not be monitored.

A nurse administers several medications to various clients diagnosed with Alzheimer disease. Which medication would be expected to stabilize levels of glutamate rather than inhibit cholinesterase?

Memantine. Rationale: Memantine normalizes levels of the neurotransmitter glutamate, which in excessive quantities contributes to neurodegeneration. Donepezil, rivastigmine, and galantamine do not stabilize glutamate levels but instead inhibit cholinesterase.

Three days after beginning a new regimen of haloperidol 10 mg BID, the nurse observes a hospitalized client is drooling, has stiff and extended extremities, and the skin is damp and hot to the touch. The client has difficulty responding verbally to the nurse. What is the nurse's correct analysis and action in this situation?

Neuroleptic malignant syndrome has developed; prepare the client for immediate transfer to a medical unit. Rationale: The client's symptoms of severe muscle rigidity, dysphasia, and an elevated temperature indicate neuroleptic malignant syndrome which can occur within the first week of antipsychotic drug therapy. The client is not demonstrating the symptoms of a seizure. Serotonin syndrome is not likely to be caused by haloperidol, and the client's symptoms do not suggest the syndrome is occurring. Because the client is not experiencing acute spasms of the tongue, jaw, face, neck, or back, he or she is not demonstrating an acute dystonic reaction.

What should the plan of care for a client who takes lithium include?

Periodic laboratory monitoring of renal and thyroid function. Rationale: Two major long-term risks of lithium therapy are hypothyroidism and impairment of the kidneys' ability to concentrate urine; therefore, a person receiving lithium therapy must have periodic follow-ups to assess thyroid and renal function. Weight gain is a common side effect of lithium, but the client should not stop taking the medication. Sodium intake for clients who take lithium is not restricted. Fine tremors are a common side effect associated with this medication, but the client should continue taking the medication.

The client states to the nurse, "I know you are not really a nurse. You are in the CIA and want to assassinate me." What type of delusion is the client displaying?

Persecutory. Rationale: This client is experiencing persecutory delusions, the false belief that the client is being singled out for harm by others. Grandiose delusions are the false belief that one is a very powerful and important person. Somatic delusions are the false belief that the body is changing in an unusual way. Tangentially is a positive formal thought disorder and speech pattern.

With a serum lithium level of 0.8 mEq/L, which assessment data does the nurse expect to observe?

Polyuria, mild thirst, and fine hand tremors. Rationale: Expected side effects for a 0.4-1.0 mEq/L lithium level (therapeutic level) include polyuria, mild thirst, and fine hand tremors. Diarrhea and muscle weakness are early signs of toxicity.

What are the most common characteristics of early onset schizophrenia?

Poorer premorbid adjustment, prominent negative symptoms, and more often diagnosed in males. Rationale: Individuals with an early onset (18-25 years) of schizophrenia have poorer premorbid adjustment, have more prominent negative symptoms, and are more often male. They do not have better outcomes or less evidence of structural brain defects.

The term "perceptual disturbance" refers to difficulty accomplishing what task?

Processing information about one's internal and external environment. Rationale: Perceptual disturbance refers to an impaired ability to process intellectual, sensory, and emotional data in a logical, meaningful way. Changing one's way of thinking to accommodate new information, performing purposeful motor movements, and formulating words appropriately fail to adequately describe the term perceptual disturbance.

What is the sequence of phases in the course of the schizophrenia?

Prodromal, acute, stabilization, maintenance. Rationale: Prodromal, acute, stabilization, and maintenance are the sequence of phases in the course of the disease.

A client experiencing an inability to recognize reality is exhibiting which symptom?

Psychosis. Rationale: A client who is experiencing an inability to recognize reality is exhibiting psychosis. All individuals experience sensory perceptions. Schizophrenia is a diagnosis not a symptom. Hallucinations are alterations in perceptions.

What intervention can the nurse do to impact the most people at potential risk for depression among a population?

Routinely assess all chronically ill clients for depression during their admission interview. Rationale: A high incidence of depression is found among all clients hospitalized for medical illnesses. These depressions are largely unrecognized and untreated by general health care providers. Studies suggest that about one third of medical inpatients report mild or moderate symptoms of depression and up to one fourth may have major depression. Chronic medical conditions often are associated with depression. While targeting school-age children, older adults, and postpartum mothers would be helpful for these specific populations as well, targeting chronically ill clients would impact the most people.

What is a relatively stable disorder with few individuals progressing to schizophrenia?

Schizotypal personality disorder. Rationale: A diagnosis of schizotypal personality disorder is a relatively stable disorder with few individuals progressing to schizophrenia. A client diagnosed with a delusional disorder will experience a course of disease, which ranges from remission without relapse to chronic waxing and waning. In the course of a schizophreniform disorder, the symptoms may last only a short time, from 1 to 6 months. Impaired social or occupational functioning is usually not apparent. The client diagnosed with a schizoaffective disorder has a better prognosis than schizophrenia, but significantly worse than a mood disorder.

Which is an advanced but not severe sign of lithium toxicity?

Sedation. Rationale: Sedation is an advanced sign of lithium toxicity when the blood plasma level of lithium is 1.5-2.0 mEq/L. Polyuria is an early sign of lithium toxicity when the blood plasma level of lithium is 1.5 mEq/L. Mild thirst is an expected side effect of lithium when the blood plasma level of lithium is 0.4-1.0 mEq/L. Blurred vision usually occurs when lithium toxicity is severe and blood levels are 2.0-2.5 mEq/L.

A nurse prepares the plan of care for a client having a manic episode. Which nursing diagnoses are most likely to apply?

Sleep deprivation, disturbed thought processes, and risk for deficient fluid volume. Rationale: A person experiencing mania sleeps poorly, has disturbed thought processes does not take time to eat or drink, which may result in fluid imbalance. Impaired social interaction rather than social isolation may occur. Because people experiencing mania do not take time to eat or drink, the client is at risk for altered nutrition due to less than body requirements rather than more than body requirements.

When is a client diagnosed with seasonal affective disorder likely to begin experiencing fewer symptoms?

Spring. Rationale: Seasonal affective disorder occurs during the months when sunlight diminishes. Clients may begin to feel effects in the late fall and will be affected throughout the winter. They improve during the spring and feel well during the summer.

A client remains motionless for long periods of time and at times appears to be in a coma. How can this state be described?

Stupor. Rationale: Stupor refers to a state in which the catatonic client is motionless for long periods and may even appear to be in a coma. Waxy flexibility is excessive maintenance of unusual postures for long periods of time. In active negativism,clients do the opposite of what they are told to do. Automatic obedience is the performance by a catatonic client of all simple commands in a robot-like fashion.

Which statement is true of the relationship between bipolar disorder and suicide?

Suicide is a serious risk, because nearly 20% of those diagnosed with bipolar disorder commit suicide. Rationale: Mortality rates for bipolar disorder are severe because 25% to 50% of individuals with bipolar disorder will make a suicide attempt at least once in their lifetimes, and the suicide rate of bipolar individuals is 15% to 20%. Suicides occur in both the depressed and the manic phases. Bipolar clients are always considered high risk for suicide because of their impulsivity while in the manic phase and hopelessness when in the depressed phase. Although staying on medications may decrease risk, there is no evidence to suggest that only clients who stop medications commit suicide.

Which side effect of antipsychotic medication therapy is generally irreversible?

Tardive dyskinesia. Rationale: Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. The side effects in anticholinergic effects, pseudoparkinsonism, and dystonic reaction often appear early in therapy and can generally be minimized with appropriate treatment.

A client demonstrating delusional behavior is escalating as a result of increasing anxiety regarding his or her personal safety. Which action demonstrates that the client has an understanding of actions to de-escalate this anxiety?

The client asks that he or she be allowed to seclude themselves. Rationale: If anxiety escalates and the patient is losing control, least restrictive interventions (e.g., one-to-one therapy, last resort seclusion) are most appropriate. Self-seclusion is an example that the client understands how to manage his or her anxiety effectively. None of the other options demonstrate the necessary principles associated with anxiety de-escalation.

A nurse is caring for a client with dementia. What client behavior is typical of dementia?

The client demands the attention of the nurse. Rationale: Clients with dementia experience uncontrolled emotions and may make demands for attention. Clients often do not exercise proper hygiene habits. Repetitiveness can be seen in the clients, which means they ask repeated questions or perform repetitive actions. Decision-making is reduced, so clients with dementia are easily influenced by others.

While caring for a client with HIV, the nurse finds that the client is at risk for self-mutilation. Which symptoms would have led the nurse to this conclusion?

The client has a feeling of worthlessness and the client has suicidal ideation. Rationale: Comorbid depression can be seen in clients with HIV. Self-mutilation is a common indication of depression. It is associated with feelings of worthlessness and suicidal ideation. Depression can cause a decrease in appetite and nutritional imbalance. However, a decreased appetite does not indicate a risk for self-mutilation. The client not praying is also not a symptom of risk for self-mutilation. The inability to perform a simple task indicates reduced concentration and interest.

Which documentation in the medical record of a client diagnosed with bipolar disorder demonstrates achievement of outcomes for the continuation phase of recovery?

The client is demonstrating new problem-solving skills, the client is able to identify three early signs of relapse, the client acknowledges the need to be medication-compliant, and the client states an understanding of the cyclic nature of the disorder. Rationale: Although the overall outcome of the continuation phase is relapse prevention, many other outcomes must be accomplished to maintain relapse prevention. These outcomes include demonstrating communication and new problem-solving skills, knowledge of early signs and symptoms of relapse, adherence to the drug therapy, and an understanding of the cyclical nature of the disease. Symptom stabilization, such as addressing poor sleeping habits, is appropriate for the acute phase of recovery.

Both twin siblings were diagnosed with schizophrenia. The male twin was diagnosed at 23 years of age and the female at 31 years of age. Based on knowledge of early- and late-onset schizophrenia, which statement is true?

The female twin has a better chance for positive outcomes because of later onset. Rationale: Female clients diagnosed with schizophrenia between the ages of 25 and 35 have better outcomes than do their male counterparts who are diagnosed earlier in life. These two clients do not have the same expectation of a poor prognosis. There is no evidence suggesting that the female twin will have more positive signs of schizophrenia. It is actually less likely that the male twin will be able to live a productive life, because his earlier onset has a poorer prognosis.

A client who had undergone a hysterectomy has low self-esteem and avoids taking food. Which appropriate method does the nurse choose to reduce anorexia?

The nurse allows family members to remain with the client during meals. Rationale: Low self-esteem and reduced food intake are symptoms of depression. Clients can be encouraged to take food in the presence of their family members to increase self-esteem. Taking food rich in fiber helps reduce constipation. Small amounts of high-calorie and high-protein food should be given frequently to meet the client's nutritional demands. The client must not be given tea or coffee frequently, because they can cause insomnia.

A client believes the thoughts of others are being put into the client's mind. What type of delusion is this client experiencing?

Thought insertion. Rationale: A client who believes the thoughts of others are being put into his or her mind is experiencing thought insertion. Thought withdrawal is a belief that one's thoughts have been removed by an outside agency. Thought control can be categorized under delusions of being controlled, which is a belief that one's body or mind is controlled by an outside agency. Thought broadcasting is a belief that others can hear one's thoughts.

A nurse is performing an assessment of a client in the local community clinic. The nurse observes that the client looks older than the age mentioned in the medical record. The client avoids making eye contact with the nurse and speaks in a monotone. On examination the nurse does not find any signs and symptoms of a physical illness. Which assessment tool does the nurse use to assess the client's behavior?

Zung Depression Scale. Rationale: The nurse should use the Zung Depression Scale for assessing depression in clients. The client is given a questionnaire and asked to mark the appropriate behavior that characterizes what the client feels. The Geriatric Depression Scale is used to assess levels of depression in older adults. The Psychogeriatric Assessment Scale is used to assess cognitive impairment in older adults. The Montreal Cognitive Assessment is used to screen for mild cognitive impairments.