Mental Health Exam 2

9. The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention monitor for complications of refeeding. Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Integumentary d. Cardiovascular

ANS: D (Cardiovascular)

23. Which assessment finding best supports dissociative fugue? The patient states: a. I cannot recall why Im living in this town. b. I feel as if Im living in a fuzzy dream state. c. I feel like different parts of my body are at war. d. I feel very anxious and worried about my problems.

ANS: A (I cannot recall why I'm living in this town.)

26. A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder? a. I check where my car keys are eight times. b. My legs often feel weak and spastic. c. Im embarrassed to go out in public. d. I keep reliving a car accident.

ANS: A (I check where my car keys are eight times.)

20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patients symptoms be most acute? a. January b. April c. June d. September

ANS: A (January)

4. A patient fearfully runs from chair to chair crying, Theyre coming! They're coming! The patient does not follow the staffs directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for the patients safety. b. encourage clarification of feelings. c. respect the patients personal space. d. offer an outlet for the patients energy.

ANS: A (provide for the patient's safety)

19. A person speaking about a rival for a significant others affection says in an emotional, syrupy voice, What a lovely person. Thats someone I simply adore. The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial.

ANS: A (reaction formation)

14. A patient says, I get in trouble sometimes because I make quick decisions and act on them. Select the nurses most therapeutic response. a. Lets consider the advantages of being able to stop and think before acting. b. It sounds as though youve developed some insight into your situation. c. I bet you have some interesting stories to share about overreacting. d. Its good that youre showing readiness for behavioral change.

ANS: A (Let's consider the advantages of being able to stop and think before acting)

17. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

ANS: A (Make observations)

27. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and familys role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A (Psychoeducational)

20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression

ANS: A (Rationalization)

20. A soldier in a combat zone tells the nurse, I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind. Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: A (Reexperiencing)

9. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is: a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

ANS: A (risk for self-harm)

2. Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A (Refer requests and questions related to care to the case manager)

3. A patient diagnosed with schizophrenia says, My co-workers are out to get me. I also saw two doctors plotting to kill me. How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

ANS: B (Dangerous)

21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patients need for periods of social isolation. b. Prevent the patient from violating the nurses rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

ANS: A (Respect the patients need for periods of social isolation)

4. A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A (Risk for injury)

9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

ANS: A (Risk for other-directed violence)

24. After major reconstructive surgery, a patients wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus.

ANS: C (hippocampus)

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence c. Risk for injury b. Impaired skin integrity d. Powerlessness

ANS: A (Risk for self-directed violence)

20. A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A (maintain normal salt and fluids in the diet)

19. An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A (meals)

26. Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, I am using contraceptives. c. says, I feel full after eating a small meal. d. reports problems with dry mouth and constipation.

ANS: A (now weighs 196 pounds)

20. Physical assessment of a patient diagnosed with bulimia often reveals: a. prominent parotid glands. c. thin, brittle hair. b. peripheral edema. d. 25% underweight.

ANS: A (prominent parotid glands)

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. Genetics are associated with suicide risk. Monitoring and support are important. b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins.

ANS: A (Genetics are associated with suicide risk. Monitoring and support are important.)

4. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, Describe what you think about your present weight and how you look. Which response by the patient is most consistent with the diagnosis? a. I am fat and ugly. b. What I think about myself is my business. c. Im grossly underweight, but thats what I want. d. Im a few pounds overweight, but I can live with it.

ANS: A (I am fat and ugly)

22. A student says, Before taking a test, I feel very alert and a little restless. Which nursing intervention is most appropriate to assist the student? a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects. b. Advise the student to discuss this experience with a health care provider. c. Encourage the student to begin antioxidant vitamin supplements. d. Listen attentively, using silence in a therapeutic way.

ANS: A (Explain that the symptoms result from mild anxiety and discuss the helpful aspects)

15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36 C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5 C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7 C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

ANS: A (150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg)

18. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patients head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A (Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record)

8. Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of blackouts despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

ANS: A (After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing.)

12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition

ANS: A (Allowing the patient supervised access to food vending machines)

17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurses response? a. Altruism b. Suppression c. Intellectualization d. Reaction formation

ANS: A (Altruism)

17. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patients head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A (An acute dystonic reaction)

12. A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurses office, furnished with chairs, files, magazines, and bookcases

ANS: A (An interview room furnished with a desk and two chairs)

18. A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you became depressed.

ANS: A (Are you having thoughts of suicide?)

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: A (As depression lifts, physical energy becomes available to carry out suicide)

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

ANS: A (Assess lung sounds and extremities)

14. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

ANS: A (Assist the patient to identify triggers to binge eating)

29. A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patients family during this phase of treatment? a. Attending psychoeducation sessions c. Increasing food and fluids b. Decreasing physical activity d. Meeting self-care needs

ANS: A (Attending psychoeducation sessions)

24. Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. Converses with few interruptions; clothing matches; participates in activities. b. Irritable, suggestible, distractible; napped for 10 minutes in afternoon. c. Attention span short; writing copious notes; intrudes in conversations. d. Heavy makeup; seductive toward staff; pressured speech.

ANS: A (Converses with few interruptions; clothing matches; participates in activities)

11. A patient diagnosed with bipolar disorder commands other patients, Get me a book. Take this stuff out of here, and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: Lets go to the dining room for a snack. b. Humor: How much are you paying servants these days? c. Limit setting: You must stop ordering other patients around. d. Honest feedback: Your controlling behavior is annoying others.

ANS: A (Distraction: Let's go to the dining room for a snack)

2. A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, Do you like my scarves? Here; they are my gift to you. How should the nurse document the patients mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A (Euphoric)

5. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, He would still be alive if you had given him your undivided attention. Select the nurses best intervention. a. Say to the wife, I understand you are feeling upset. I will stay with you until your family comes. b. Say to the wife, Your husbands heart was so severely damaged that it could no longer pump. c. Say to the wife, I will call the health care provider to discuss this matter with you. d. Hold the wifes hand in silence until the family arrives.

ANS: A (Say to the wife, I understand you are feeling upset. I will stay with you until your family comes.)

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A (Sedation and muscle stiffness)

19. Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated project was a failure, just like me. c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, I feel tired all the time.

ANS: A (Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.)

4. An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy

ANS: A (Social skills training)

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A (Supervise the patient 24 hours a day.)

12. A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurses comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: A (The nurse interacts with the patient in a protective fashion)

33. A nurse asks a patient diagnosed with schizophrenia, What is meant by the old saying You cant judge a book by looking at the cover.? Which response by the patient indicates concrete thinking? a. The table of contents tells what a book is about. b. You cant judge a book by looking at the cover. c. Things are not always as they first appear. d. Why are you asking me about books?

ANS: A (The table of contents tells what a book is about.)

13. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurses best plan. a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurses identity; encourage the patient to talk while the nurse works on reports.

ANS: A (Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return)

22. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A (Withdrawal, misinterpreting, poor concentration, and preoccupation with religion)

38. A newly hospitalized patient experiencing psychosis says, Red chair out town board. Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

ANS: A (Word salad)

29. A patient diagnosed with schizophrenia begins to talks about macnabs hiding in the warehouse at work. The term macnabs should be documented as: a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A (a neologism)

34. Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder.

ANS: A (bipolar I disorder)

25. Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

ANS: A (engage the parasympathetic NS)

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, We should have seen this coming. We did not do enough. The parents reaction reflects: a. guilt. c. shame. b. denial. d. rescue feelings.

ANS: A (guilt)

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A (hopelessness)

9. The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A (several factors, including genetics, are implicated)

2. A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

ANS: A (verbalize realistic positive characteristics about self by (date))

12. The nurse receives a laboratory report indicating a patients serum level is 1 mEq/L. The patients last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A (within therapeutic limits)

2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, Two staff members I saw talking were plotting to kill me. Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B (Risk for other-directed violence, disturbed thought processes)

2. Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arms-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patients eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

ANS: A, B, C (Maintain arms-length, one-on-one direct observation at all times, check all items brought by visitors and remove risk items, use plastic eating utensils; count utensils upon collection)

3. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

ANS: A, B, C (Offer laxatives if needed, monitor food and fluid intake, provide a quiet sleep environment)

2. For which patients diagnosed with personality disorders would a family history of similar problems be most likely? Select all that apply. a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

ANS: A, B, C, D (Obsessive-compulsive, antisocial, borderline, schizotypal)

2. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) a. conveying empathy and acknowledging the childs distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

ANS: A, B, C, E (conveying empathy and acknowledging the childs distress, explaining and reinforcing reality to avoid distortions, using a calm manner and low, comforting voice, staying with the child until the anxiety decreases)

3. The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

ANS: A, B, C, E, F (avoids people and places that arouse painful memories, experiences flashbacks or reexperiences the trauma, experiences symptoms suggestive of a heart attack, demonstrates hypervigilance or distrusts others, feels detached, estranged, or empty inside)

1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

ANS: A, B, D (82-year-old white male, 17-year-old white female, 19-year-old Native American male)

1. A young adult says, I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I dont remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them. Which disorders should the nurse suspect based on this history? Select all that apply. a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

ANS: A, B, D (Acute stress disorder, depersonalization disorder, PTSD)

1. Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patients sleep patterns.

ANS: A, B, E (Limit credit card access, provide a structured environment, monitor the patient's sleep patterns)

1. A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.

ANS: A, B, E (Use a calm manner and low voice, maintain simplicity in the environment, explain and reinforce reality to avoid distortions)

3. A patient tells the nurse, I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family. These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C (Powerlessness, chronic low self-esteem)

2. A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new prescription for lorazepam (Ativan). What information should be included? Select all that apply. a. Caution in use of machinery b. Foods allowed on a tyramine-free diet c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives e. Take the medication on an empty stomach

ANS: A, C, D (Caution in use of machinery, the importance of caffeine restriction, avoidance of alcohol and other sedatives)

3. A college student is extremely upset after failing two examinations. The student said, No one understands how this will hurt my chances of getting into medical school. The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

ANS: A, C, D, E (Shame, humiliation, self-imposed isolation, recent stressful life event)

2. A student nurse caring for a patient diagnosed with depression reads in the patients medical record, This patient shows vegetative signs of depression. Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

ANS: A, C, D, F (Imbalanced nutrition: less than body requirements, sexual dysfunction, self-care deficit, insomnia)

1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

ANS: A, C, D, F (peripheral edema, constipation, hypotension, lanugo)

4. The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? Select all that apply. a. Ineffective home maintenance b. Situational low self-esteem c. Chronic low self-esteem d. Disturbed body image e. Risk for injury

ANS: A, C, E (Ineffective home maintenance, chronic low self-esteem, risk for injury)

4. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, I took a few extra tablets earlier today and now I feel bad. Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

ANS: A, D, E (Vital signs, presence of abdominal pain and diarrhea, hyperactivity of feelings of restlessness)

1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a. The importance of taking your medication correctly b. How to complete an application for employment c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking

ANS: A, E (The importance of taking your medication correctly, ways to quit smoking)

10. The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. A high proportion of patients with bipolar disorders are found among creative writers. b. A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder. c. Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress. d. More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.

ANS: B (A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder)

23. During a psychiatric assessment, the nurse observes a patients facial expression is without emotion. The patient says, Life feels so hopeless to me. Ive been feeling sad for several months. How will the nurse document the patients affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

ANS: B (Affect flat; mood depressed)

2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

ANS: B (An idea of reference)

28. The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia? a. Im sure I will get over not wanting to leave home soon. It takes time. b. Being afraid to go out seems ridiculous, but I cant go out the door. c. My family says they like it now that I stay home most of the time. d. When I have a good incentive to go out, I can do it.

ANS: B (Being afraid to go out seems ridiculous, but I can't go out the door.)

2. A woman is 57, 160 lbs, and wears a size 8 shoe. She says, My feet are huge. Ive asked three orthopedists to surgically reduce my feet. This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a. Social anxiety disorder b. Body dysmorphic disorder c. Separation anxiety disorder d. Obsessive-compulsive disorder due to a medical condition

ANS: B (Body dysmorphic disorder)

10. A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patients anxiety. b. Concerns stated aloud become less overwhelming and help problem solving begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

ANS: B (Concerns stated aloud become less overwhelming and help problem solving begin.)

6. A patients care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

ANS: B (Darting eyes, tilted head, mumbling to self)

21. Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B (Disturbed sleep pattern)

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents?

ANS: B (Do you have access to medications?)

30. A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patients symptoms rather than on the patient.

ANS: B (Encourage the patient to participate in social activities.)

12. A patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patients behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication.

ANS: B (Engage the patient in a physical activity such as exercise)

1. A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support numbing as a temporary way to manage intolerable feelings.

ANS: B (Explain that the physical symptoms are related to the psychological state.)

17. A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, If theres a loud noise at night, I get under my bed because I think were getting bombed. What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

ANS: B (Flashback)

14. The gas pedal on a persons car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this persons cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis

ANS: B (Flashbacks)

1. An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patients history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

ANS: B (Fluoxetine (Prozac), a selective serotonin reuptake inhibitor)

3. After the sudden death of his wife, a man says, I cant live without her she was my whole life. Select the nurses most therapeutic reply. a. Each day will get a little better. b. Her death is a terrible loss for you. c. Its important to recognize that she is no longer suffering. d. Your friends will help you cope with this change in your life.

ANS: B (Her death is a terrible loss for you)

16. A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B (Hold staff meeting to discuss consistency and limit-setting approaches)

23. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

ANS: B (Hold staff meeting to express feelings and plan care for the other patients)

22. Which statement by a depressed patient will alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one to turn to for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I cut myself last time.

ANS: B (I have no one to turn to for help or support)

29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a. They will put me to sleep during the procedure so I wont know what is happening. b. I might be a little dizzy or have a mild headache after each procedure. c. I will be unable to care for my children for about 2 months. d. I will avoid eating foods that contain tyramine.

ANS: B (I might be a little dizzy or have a mild headache after each procedure.)

9. A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c. Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family.

ANS: B (Present the information again in a calm manner using a simple language.)

16. Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurses immediate attention? a. Its good to be home. I missed my home, family, and friends. b. I saw my best friend get killed by a roadside bomb. I dont understand why it wasnt me. c. Sometimes I think I hear bombs exploding, but its just the noise of traffic in my hometown. d. I want to continue my education, but Im not sure how I will fit in with other college students.

ANS: B (I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me.)

30. A patient says, The other nurses wont give me my medication early, but you know what its like to be in pain and dont let your patients suffer. Could you get me my pill now? I wont tell anyone. Which response by the nurse would be most therapeutic? a. Im not comfortable doing that, and then ignore subsequent requests for early medication. b. I understand that you have pain, but giving medicine too soon would not be safe. c. Ill have to check with your doctor about that; I will get back to you after I do. d. It would be unsafe to give the medicine early; none of us will do that.

ANS: B (I understand that you have pain, but giving medicine too soon would not be safe)

10. A patient diagnosed with major depression tells the nurse, Bad things that happen are always my fault. Which response by the nurse will best assist the patient to reframe this overgeneralization? a. I really doubt that one person can be blamed for all the bad things that happen. b. Lets look at one bad thing that happened to see if another explanation exists. c. You are being extremely hard on yourself. Try to have a positive focus. d. Are you saying that you don't have any good things happen?

ANS: B (Let's look at one bad thing that happened to see if another explanation exists)

1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first? a. Verify the patients learning style. b. Lower the patients current anxiety. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.

ANS: B (Lower the patient's current anxiety)

37. A patient insistently states, I can decipher codes of DNA just by looking at someone. Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

ANS: B (Magical thinking)

12. What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

ANS: B (Maintaining consistent limits)

13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

ANS: B (Mashed potatoes, ground beef patty, corn, green beans, apple pie)

8. A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurses comments and asks, What do you mean? What are they going to do? Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patients level of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: B (Moderate)

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI)

ANS: B (Mood stabilizing medication)

15. At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B (Neutral walls with pale, simple accessories)

7. Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patients feelings. d. Help the patient balance energy expenditures with caloric intake.

ANS: B (Observe for adverse effects of refeeding)

26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl)

ANS: B (Olanzapine (Zyprexa))

8. A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes compliance with treatment. c. Because of increased risk of physical problems with refeeding, the patients permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

ANS: B (Patient involvement in decision making increases sense of control and promotes compliance with treatment)

10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patients activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B (Perform self-care activities with coaching by the end of day 3)

1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? Select all that apply. a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D (Callous attitude, aggression)

25. A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B (Provide a subdued environment)

5. A patient fearfully runs from chair to chair crying, Theyre coming! Theyre coming! The patient does not follow the staffs directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Fear b. Risk for injury c. Self-care deficit d. Disturbed thought processes

ANS: B (Risk for injury)

21. A patient diagnosed with depression repeatedly tells staff, I have cancer. Its my punishment for being a bad person. Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

ANS: B (Risk for suicide)

4. Which change in the brains biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B (Serotonin deficiency)

14. When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B (Set limits on patient behavior as necessary)

31. A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, Do I have to keep taking this lithium even though my mood is stable now? Select the nurses appropriate response. a. You will be able to stop the medication in about 1 month. b. Taking the medication every day helps reduce the risk of a relapse. c. Usually patients take medication for approximately 6 months after discharge. d. It's unusual that the health care provider hasn't already stopped your medication.

ANS: B (Taking medication every day helps reduce the risk of a relapse)

19. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patients neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourettes syndrome d. Anticholinergic effects

ANS: B (Tardive dyskinesia)

35. A client says, Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist. Select the nurses best initial action. a. Tell the client, Facebook is a safe website. You don't need to worry about Homeland Security. b. Tell the client, You are in a safe place where you will be helped. c. Administer a PRN dose of an antipsychotic medication. d. Tell the client, You don;t need to worry about that.

ANS: B (Tell the client, you are in a safe place where you will be helped.)

5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a. I hear angels playing harps. b. The voices say everyone is trying to kill me. c. My dead father tells me I am a good person. d. The voices talk only at night when I'm trying to sleep.

ANS: B (The voices say everyone is trying to kill me.)

11. The unlicensed assistive personnel (UAP) says to the nurse, That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her? Select the nurses best reply. a. Spend as much time with her as you can and ask questions about her life. b. Use short, simple sentences and keep the environment calm and protective. c. Provide more information about her past to reduce the mysteries that are causing anxiety. d. Structure her time with activities to keep her busy, stimulated, and regaining concentration.

ANS: B (Use short, simple sentences and keep the environment calm and protective)

11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B (Wavy flexibility)

24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 56 and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B (Weight management strategies)

3. A patient diagnosed with major depression says, No one cares about me anymore. I'm not worth anything. Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. You look nice this morning. b. You're wearing a new shirt. c. I like the shirt you are wearing. d. You must be feeling better today.

ANS: B (You're wearing a new shirt)

7. A patient says to the nurse, My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day. The nurse documents this report as an example of: a. dysthymia. c. euphoria. b. anhedonia. d. anergia.

ANS: B (anhedonia)

7. A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B (bring hyperactivity under rapid control)

5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

ANS: B (careful unobtrusive observation around the clock)

28. A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, Ill throw the pool balls if anyone comes near me. To best assure safety, the nurses first intervention is to: a. tell the patient, You need to be secluded. b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B (clear the room of all other patients)

23. Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B (distorted thought self-control)

6. This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days.Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B (drink six servings of high-calorie, high-protein drink each day)

32. An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, Ive had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do? The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

ANS: B (have someone bring the patient to the clinic immediately)

28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

ANS: B (hypertensive crisis)

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

ANS: B (impaired social interaction)

18. A patient waves a newspaper and says, I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes. Select the nurses appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B (invites the patient to sit together and look at new fashion magazines)

16. A patient experiences a sudden episode of severe anxiety. Of these medications in the patients medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)

ANS: B (lorazepam (Ativan))

11. An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient: a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.

ANS: B (not to skip meals or restrict food)

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

ANS: B (perfectionist, inflexible)

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

ANS: B (provide care in a matter-of fact manner)

21. Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

ANS: B (rigidity, perfection)

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, You used to care about me. I thought you were wonderful. Now I can see I was wrong. Youre evil. This outburst can be assessed as: a. denial. b. splitting. c. defensive. d. reaction formation.

ANS: B (splitting)

14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

ANS: B Supporting physiological stability

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, They're all plotting to destroy me. Isn't that true? Select the nurses most therapeutic response. a. Everyone here is trying to help you. No one wants to harm you. b. Feeling that people want to destroy you must be very frightening. c. That is not true. People here are trying to help you if you will let them. d. Staff members are health care professionals who are qualified to help you.

ANS: B (Feeling that people want to destroy you must be very frightening.)

2. A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C (Disturbed thought processes, sleep deprivation)

3. Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. Are there certain social situations that cause you to feel especially uncomfortable? b. Are there others in your family who must do things in a certain way to feel comfortable? c. Have you been a victim of a crime or seen someone badly injured or killed? d. Is it difficult to keep certain thoughts out of your awareness? e. Do you do certain things over and over again?

ANS: B, D, E (Are there others in your family who must do things in a certain way to feel comfortable?; Is it difficult to keep certain thoughts out of your awareness?; Do you do certain things over and over again?)

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patients needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C (Ability to provoke interpersonal conflict)

4. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, If you had given him your undivided attention, he would still be alive. How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

ANS: C (Anger is an expected emotion in an adjustment disorder)

1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

ANS: C (Anorexia nervosa)

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

ANS: C (Attending a self-help group for survivors)

20. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social support

ANS: C (Availability of means and lethality of method)

21. A soldier who served in a combat zone returned to the U.S. The soldiers spouse complains to the nurse, We had planned to start a family, but now he wont talk about it. He wont even look at children. The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: C (Avoidance)

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

ANS: C (Avoidant)

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, I am considering committing suicide. a. Im glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to keep you safe. c. Bringing up these feelings is a very positive action on your part. d. We need to talk about the good things you have to live for.

ANS: C (Bringing up these feelings is a very positive action on your part)

22. Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C (Broiled chicken breast on a roll, an ear of corn, and an apple)

10. A patient states, I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school. This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

ANS: C (Depersonalization disorder)

30. A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C (Diaphoresis, weakness, and nausea)

5. A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. Stop that! No one did anything to provoke an attack by you. b. If you do that one more time, you will be secluded immediately. c. Do not hit anyone. If you are unable to control yourself, we will help you. d. You know we will not let you hit anyone. Why do you continue this behavior?

ANS: C (Do not hit anyone. If you are unable to control yourself, we will help you.)

10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the patients wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the patients behavior.

ANS: C (External controls are necessary due to failure of internal control)

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not in any way attempt to harm or kill myself. d. I will not kill myself until I call my primary nurse or a member of the staff.

ANS: C (For the next 24 hours, I will not make any attempt to harm or kill myself.)

5. A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

ANS: C (Giving away sweaters)

3. A person was directing traffic on a busy street, rapidly shouting, To work, you jerk, for perks and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patients plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C (Hyperactivity; not eating and sleeping)

16. Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. I think you are the best nurse on the unit. b. Im never going to get high on drugs again. c. I felt empty and wanted to hurt myself, so I called you. d. I hate my mother. I called her today, and she wasnt home.

ANS: C (I felt empty and wanted to hurt myself, so I called you)

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me.

ANS: C (I have a plan that will fix everything)

15. A newly admitted patient diagnosed with schizophrenia says, The voices are bothering me. They yell and tell me I am bad. I have got to get away from them. Select the nurses most helpful reply. a. Do you hear the voices often? b. Do you have a plan for getting away from the voices? c. I'll stay with you. Focus on what we are talking about, not the voices. d. Forget the voices and ask some other patients to play cards with you.

ANS: C (I'll stay with you. Focus on what we are talking about, not the voices.)

3. A patient experiencing moderate anxiety says, I feel undone. An appropriate response for the nurse would be: a. What would you like me to do to help you? b. Why do you suppose you are feeling anxious? c. Im not sure I understand. Give me an example. d. You must get your feelings under control before we can continue.

ANS: C (I'm not sure I understand. Give me an example.)

17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

ANS: C (Lanugo)

9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

ANS: C (Physiological)

1. A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C (Poor judgment and hyperactivity)

21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

ANS: C (Poor personal hygiene)

36. Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

ANS: C (Poverty of thought)

14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, The nurse manager had a headache the day I was interviewed. Which defense mechanism is evident? a. Introjection c. Projection b. Conversion d. Splitting

ANS: C (Projection)

16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a.Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C (Pseudoparkinsonism)

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, Just leave it on the table. Ill take it when I finish combing my hair. What is the nurses best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, Im worried that you might not take it. Ill come back later. c. Say to the patient, I must watch you take the medication. Please take it now. d. Ask the patient, Why dont you want to take your medication now?

ANS: C (Say to the patient, I'm worried that you might not take it. I'll come back later.)

13. A person has minor physical injuries after an auto accident. The person is unable to focus and says, I feel like something awful is going to happen. This person has nausea, dizziness, tachycardia, and hyperventilation. What is the persons level of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: C (Severe)

13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

ANS: C (Sympathetic NS)

25. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, This medicine isnt working. The nurses best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

ANS: C (explain the time lag before antidepressants relieve symptoms)

18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares. The nurse will advise the patient to: a. Go to the nearest emergency department immediately. b. Do not to be alarmed. Take two aspirin and drink plenty of fluids. c. Take a dose of your antidepressant now and come to the clinic to see the health care provider. d. Resume taking your antidepressants for 2 more weeks and then discontinue them again.

ANS: C (Take a dose of your antidepressant now and come to the clinic to see the health care provider)

24. A patient experiencing panic suddenly began running and shouting, Im going to explode! Select the nurses best action. a. Ask, Im not sure what you mean. Give me an example. b. Capture the patient in a basket-hold to increase feelings of control. c. Tell the patient, Stop running and take a deep breath. I will help you. d. Assemble several staff members and say, We will take you to seclusion to help you regain control.

ANS: C (Tell the patient, stop running and take a deep breath. I will help you.)

27. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

ANS: C (Temporary memory impairments and confusion may occur with electroconvulsive therapy.)

23. A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism? a. I dont know why I do mean things. b. I have always had poor impulse control. c. That person should not have provoked me. d. Im really a coward who is afraid of being hurt.

ANS: C (That person should not have provoked me.)

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C (Verbal abuse of another patient)

3. A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: a. Do you often feel fat? b. Who plans the family meals? c. What do you eat in a typical day? d. What do you think about your present weight?

ANS: C (What do you eat in a typical day?)

27. A new psychiatric technician says, Schizophreniaschizotypal! Whats the difference? The nurses response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

ANS: C (With schizotypal personality disorder, the patient remains psychotic much longer)

4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C (acknowledge manipulative behavior when it is called to his or her attention)

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

ANS: C (acting without thought on urges or desires)

11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, I feel empty and want to hurt myself. The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

ANS: C (assist the patient to choose coping strategies for triggering situations)

27. When alprazolam (Xanax) is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to: a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.

ANS: C (avoid alcoholic beverages)

6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

ANS: C (cognitive behavioral therapy)

15. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurses highest priority is to screen this soldier for: a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

ANS: C (depression)

13. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide.

ANS: C (establish rapport with the patient)

27. A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center.

ANS: C (has accidents of defecation at kindergarten three times a week)

16. A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

ANS: C (how to recognize hypokalemia)

15. A patient tells a nurse, My new friend is the most perfect person one could imagine: kind, considerate, and good-looking. I cant find a single flaw. This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation.

ANS: C (idealization)

13. Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

ANS: C (lamotrigine (Lamictal))

5. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, Another nurse said you dont do your job right. Collectively, these interactions can be assessed as: a. seductive. b. detached. c. manipulative. d. guilt-producing.

ANS: C (manipulative)

29. A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis? a. feelings of responsibility for the health of family members b. approval-seeking behavior from friends and family c. persistent thoughts about bacteria, germs, and dirt d. needs to avoid interactions with others

ANS: C (persistent thoughts about bacteria, germs, and dirt)

19. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients concentration and attention. b. shifting the patients focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.

ANS: C (promoting processing of anxiety associated with eating)

17. A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, Why dont you put your clothes on? b. firmly telling the patient, Stop dancing and put on your clothing. c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C (putting a blanket around the patient and walking with the patient to a quiet room)

12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

ANS: C (reporting increased suicidal thoughts)

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C (risk for suicide)

16. Major depression resulted after a patients employment was terminated. The patient now says to the nurse, Im not worth the time you spend with me. I am the most useless person in the world. Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

ANS: C (situational low self-esteem)

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C (suicide potential)

8. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, I dont think I can keep taking these pills. They make me so dizzy, especially when I stand up. The nurse will: a. limit the patients activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patients mental status examination.

ANS: C (teach the patient strategies to manage postural hypotension)

4. The plan of care for a patient in the manic state of bipolar disorder should include which interventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patients nutritional needs are met. e. Design activities that require the patients concentration.

ANS: C, D (Provide a structured environment for the patient, ensure that the patients nutritional needs are met)

2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

ANS: C, D, E (Adherence to selected menu, observation during and after meals, monitoring during bathroom trips)

4. Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply. a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

ANS: C, D, E (An adolescent was kidnapped and held for 2 years in the home of a sexual predator, a passenger was in a bus that overturned on a sharp curve and tumbled down an embankment, an adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks)

1. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

ANS: C, D, E (Instilling a sense of hopefulness, assisting with self-care activities, accommodating psychomotor retardation)

25. Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

ANS: D (A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate)

23. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. You and I will have to sit down and discuss this problem. b. It bothers me to see you exercising. I am afraid you will lose more weight. c. Lets discuss the relationship between exercise, weight loss, and the effects on your body. d. According to our agreement, no exercising is permitted until you have gained a specific amount of weight.

ANS: D (According to our agreement, no exercising is permitted until you have gained a specific amount of weight)

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine (Clozaril) b. Ziprasidone (Geodon) c. Olanzapine (Zyprexa) d. Aripiprazole (Abilify)

ANS: D (Aripiprazole (Abilify))

25. A patient diagnosed with schizophrenia says, Its beat. Time to eat. No room for the cat. What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D (Associative looseness)

14. Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D (Avoid relationships because they become anxious with emotional closeness)

10. A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. What are your feelings about not eating foods that you prepare? b. You seem to feel much better about yourself when you eat something. c. It must be difficult to talk about private matters to someone you just met. d. Being thin doesnt seem to solve your problems. You are thin now but still unhappy.

ANS: D (Being thin doesn't seem to solve your problems. You are thin now but still unhappy.)

11. A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a. Have you been a victim of a crime or seen someone badly injured or killed? b. Do you feel especially uncomfortable in social situations involving people? c. Do you repeatedly do certain things over and over again? d. Do you find it difficult to control your worrying?

ANS: D (Do you find it difficult to control your worrying?)

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D (Exercise suicide self-restraint by refraining from attempts to harm self for 24 hours)

26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

ANS: D (Eyes pointed downward)

18. A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

ANS: D (Fireworks display on July 4th)

33. A newly diagnosed patient is prescribed lithium. Which information from the patients history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D (Heart failure)

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient

ANS: D (Helping school children learn to manage stress and be resilient)

8. A patient diagnosed with schizophrenia tells the nurse, I eat skiller. Tend to end. Easter. It blows away. Get it? Select the nurses best response. a. Nothing you are saying is clear. b. Your thoughts are very disconnected. c. Try to organize your thoughts and then tell me again. d. I am having difficulty understanding what you are saying.

ANS: D (I am having difficulty understanding what you are saying.)

8. A patients spouse filed charges after repeatedly being battered. The patient sarcastically says, Im sorry for what I did. I need psychiatric help. Which statement by the patient supports an antisocial personality disorder? a. I have a quick temper, but I can usually keep it under control. b. Ive done some stupid things in my life, but Ive learned a lesson. c. Im feeling terrible about the way my behavior has hurt my family. d. I hit because I am tired of being nagged. My spouse deserves the beating.

ANS: D (I hit because I am tired of being nagged. My spouse deserves the beating.)

1. A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, No one cares about me. I'm not worth anything. Which response by the nurse would be the most helpful? a. Things will look brighter soon. Everyone feels down once in a while. b. Our staff members care about you and want to try to help you get better. c. It is difficult for others to care about you when you repeatedly say the same negative things. d. I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you.

ANS: D (I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you.)

13. A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

ANS: D (Identify two alternative methods of coping with loneliness)

5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS: D (Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia)

24. Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

ANS: D (Imbalanced nutrition: less than body requirements)

2. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted

ANS: D (Jumping from a railroad bridge located in a deserted)

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are very important and which are less important.

ANS: D (Lets consider which problems are very important and which are less important.)

32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8 F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurses best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

ANS: D (Neuroleptic malignant syndrome; notify health care provider)

22. A soldier returned home last year after deployment to a war zone. The soldiers spouse complains, We were going to start a family, but now he wont talk about it. He will not look at children. I wonder if were going to make it as a couple. Select the nurses best response. a. Posttraumatic stress disorder often changes a persons sexual functioning. b. I encourage you to continue to participate in social activities where children are present. c. Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior. d. Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support.

ANS: D (PTSD often strains relationships. Here are some community resources for help and support.)

23. A patient diagnosed with schizophrenia says, Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people. Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D (Paranoia)

2. Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance

ANS: D (Patient expresses satisfaction with body appearance)

31. For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Prepare to implement physical controls. d. Provide calm, brief, directive communication.

ANS: D (Provide calm, brief, directive communication.)

19. A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

ANS: D (Screening should be on-going)

22. Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg

ANS: D (Systolic BP 62 mm Hg)

25. A person who has been unable to leave home for more than a week because of severe anxiety says, I know it does not make sense, but I just cant bring myself to leave my apartment alone. Which nursing intervention is appropriate? a. Help the person use online video calls to provide interaction with others. b. Advise the person to accept the situation and use a companion. c. Ask the person to explain why the fear is so disabling. d. Teach the person to use positive self-talk techniques.

ANS: D (Teach the person to use positive self-talk techniques)

24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, You must bathe daily. c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

ANS: D (firmly and neutrally assist the patient with showering)

7. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurses most therapeutic response. a. Are you taking your medications the way they are prescribed? b. This loss is harder to accept because of your mental illness. Do you think you should be hospitalized? c. Im worried about how much you are crying. Your grief over your husbands death has gone on too long. d. The unexpected death of your husband is very painful. Im glad you are able to talk about your feelings.

ANS: D (The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings.)

31. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, The voice is telling me to do things. Select the nurses priority assessment question. a. How long has the voice been directing your behavior? b. Does what the voice tell you to do frighten you? c. Do you recognize the voice speaking to you? d. What is the voice telling you to do?

ANS: D (What is the voice telling you to do?)

20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurses best response. a. Why are you laughing? b. Please share the joke with me. c. I don't think I said anything funny. d. You're laughing. Tell me what's happening.

ANS: D (You're laughing. Tell me what's happening.)

27. A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D (arrange for one-on-one supervision)

8. A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) c. risperidone (Risperdal) b. clonidine (Catapres) d. carbamazepine (Tegretol)

ANS: D (carbamazepine (Tegretol))

26. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D (cognitive distortions associated with unresolved childhood abuse issues)

6. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of: a. flooding. b. desensitization. c. relaxation technique. d. cognitive restructuring.

ANS: D (cognitive restructuring)

18. A person who feels unattractive repeatedly says, Although Im not beautiful, I am smart. This is an example of: a. repression. b. devaluation. c. identification. d. compensation.

ANS: D (compensation)

15. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

ANS: D (confers with a pharmacist when selecting over-the-counter medications

26. A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patients behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patients speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D (consider the need to check lithium level. The patient may not be swallowing medications)

2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenagers grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their childs high school.

ANS: D (create a scholarship fund at their child's high school)

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

ANS: D (demonstrate ability to introduce self to a stranger in a social situation)

34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D (demonstrate improved social skills)

7. A patient undergoing diagnostic tests says, Nothing is wrong with me except a stubborn chest cold. The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial

ANS: D (denial)

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

ANS: D (fear of abandonment associated with progress toward autonomy and independence)

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.

ANS: D (gain 1 to 2 pounds)

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D (grandiosity, self-importance, an a sense of entitlement)

18. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, I wont eat until I look thin. Select the priority initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation

ANS: D (imbalanced nutrition: less than body requirements related to self-starvation)

11. A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

ANS: D (ineffectiveness and frustration)

1. A health care provider recently convicted of Medicare fraud says to a nurse, Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I should get the money. These statements show: a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

ANS: D (lack of guilt feelings)

30. A patient diagnosed with schizophrenia anxiously says, I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror. While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patients shoulders. c. place a hand on the patients arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D (maintain a normal social interaction distance from the patient)

21. A student says, Before taking a test, I feel very alert and a little restless. The nurse can correctly assess the students experience as: a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety.

ANS: D (mild anxiety)

22. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice b. Orange juice c. Hot tea d. Milk

ANS: D (milk)

28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, My computer is sending out infected radiation beams. The nurse can correctly assess this information as an indication of: a. the need for psychoeducation. b. medication noncompliance. c. chronic deterioration. d. relapse.

ANS: D (relapse)

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

ANS: D (socially anxious, rambling stories, peculiar ideas)

6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the childs parents have adapted to their loss? The parents: a. visit their childs grave daily. b. maintain their childs room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

ANS: D (throw flowers on the lake at each anniversary date of the accident)

18. For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

ANS: D (urges a suspicious patient to hit anyone who stares)

9. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

ANS: D (urinary retention)