Mental Health Quiz 3

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

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

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?

b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder."

A patient has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this patient shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response.

b. "Feeling that people want to destroy you must be very frightening."

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

d. maintain a normal social interaction distance from the patient.

A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents.

b. Help the patient identify incidents that trigger impulsive anger.

Which assessment finding presents the greatest risk for violent behavior directed at others?

b. History of spousal abuse

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?

b. Hold a staff meeting to discuss consistency and limit-setting approaches.

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."

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.)

a. "The importance of taking your medication correctly" e. "Ways to quit smoking"

A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't 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."

An acutely violent patient diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the patient's 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 50 mg IM from the prn medication administration record.

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.)

b. Impaired mood regulation c. Sleep deprivation

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient's 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

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 patient's family during this phase of treatment?

a. Attending psychoeducation sessions

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: "Let's go to the dining room for a snack."

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 patient's mood?

a. Euphoric

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence?

a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

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. d. Supervise medication administration. e. Monitor the patient's sleep patterns.

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 c. Chronic low self-esteem

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize?

a. Practice and teamwork

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend?

a. Psychoeducational

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol 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

Which behavior best demonstrates aggression?

a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

What assessment findings mark the prodromal stage of schizophrenia?

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

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

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.

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.

A health teaching plan for a patient taking lithium should include instructions to

a. maintain normal salt and fluids in the diet.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should

a. make sure there is adequate physical space between the nurse and patient.

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.

The exact cause of bipolar disorder has not been determined; however, for most patients

a. several factors, including genetics, are implicated.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is

a. within therapeutic limits.

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?

b. "My fingers are tingly."

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 nurse's appropriate response.

b. "Taking the medication every day helps reduce the risk of a relapse."

Which hallucination necessitates the nurse to implement safety measures? The patient says,

b. "The voices say everyone is trying to kill me."

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?

b. Dangerous

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

b. Darting eyes, tilted head, mumbling to self

Which nursing diagnosis would most likely apply to a patient diagnosed with major depressive disorder as well as one experiencing acute mania?

b. Disturbed sleep pattern

A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications?

b. Gynecomastia

A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident?

b. Magical thinking

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate?

b. Neutral walls with pale, simple accessories

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?

b. Olanzapine

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?

b. Provide a subdued environment.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention?

b. Set limits on patient behavior as necessary.

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, "I'm in pain all the time but you don't give me medicine until YOU think it's time." Which nursing intervention would best address this problem?

b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.

A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

b. Tardive dyskinesia

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action.

b. Tell the client, "You are in a safe place where you will be helped."

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?

b. Waxy flexibility

An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room

b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control."

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

b. an idea of reference.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? It will

b. bring hyperactivity under rapid control.

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, "I'll throw the pool balls if anyone comes near me." To best assure safety, the nurse's first intervention is to

b. clear the room of all other patients.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on

b. distorted thought self-control.

This nursing diagnosis applies to a patient experiencing 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

b. drink six servings of a high-calorie, high-protein drink each day.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've 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

b. have someone bring the patient to the clinic immediately.

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 nurse's appropriate intervention. The nurse

b. invites the patient to sit together and look at new fashion magazines.

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will

b. perform self-care activities with coaching by the end of day 3.

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?

c. "Do not hit anyone. If you are unable to control yourself, we will help you."

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say:

c. "I'd like to talk with you about how you're feeling right now."

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 nurse's most helpful reply.

c. "I'll stay with you. Focus on what we are talking about, not the voices. "

A nurse educates a patient about the antipsychotic medication regime. Afterward, which comment by the patient indicates the teaching was effective?

c. "Taking this medication regularly will reduce the severity of my symptoms."

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say:

c. "You want to go home to prepare your husband's dinner?"

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care?

c. A wish for revenge

Which dinner menu is best suited for a patient with acute mania?

c. Broiled chicken breast on a roll, an ear of corn, and an apple

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?

c. Diaphoresis, weakness, and nausea

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 patient's plan of care?

c. Hyperactivity; not eating and sleeping

Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention?

c. Olanzapine

Which clinical scenario predicts the highest risk for directing violent behavior toward others?

c. Paranoid delusions of being followed by alien monsters

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger?

c. Periodically provide an update and progress report on the patient.

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

c. Physiological

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?

c. Poor judgment and hyperactivity

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

c. Poor personal hygiene

Which finding constitutes a negative symptom associated with schizophrenia?

c. Poverty of thought

The plan of care for a patient in the manic state of bipolar disorder should include which interventions? (Select all that apply.)

c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met.

A patient diagnosed with schizophrenia has taken fluphenazine 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?

c. Pseudoparkinsonism

A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The patient is 5'6'' and currently weighs 204 lbs. The patient has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the patient's plan of care?

c. Weight management strategies

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification?

c. lamotrigine

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by

c. putting a blanket around the patient and walking with the patient to a quiet room.

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by

c. saying to the patient, "This is a safe place."

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's most therapeutic response.

d. "I am having difficulty understanding what you are saying."

A patient diagnosed with schizophrenia anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question.

d. "What is the voice telling you to do?"

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 nurse's most therapeutic response.

d. "You're laughing. Tell me what's happening."

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?

d. Aripiprazole

A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident?

d. Associative looseness

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 patient's behavior?

d. Consider the need to check the lithium level. The patient may not be swallowing medications.

A patient with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which action by the nurse will best help to diffuse the patient's anger?

d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical?

d. Heart failure

A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective?

d. Invite participants to come up with solution to getting incorrect change for a purchase.

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 nurse's best analysis and action.

d. Neuroleptic malignant syndrome; notify health care provider stat.

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?

d. Paranoia

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority?

d. Risk for other-directed violence

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action?

d. The patient interpreted the UAP's behavior as potentially harmful.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should

d. arrange for one-on-one supervision.

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?

d. carbamazepine

The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group? Members will

d. demonstrate improved social skills.

A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is

d. exhibiting clues to potential aggression.

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient

d. presented a clear and present danger to others.

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

d. relapse.

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of

d. substance abuse.