MHF

A nurse is caring for four clients diagnosed with major depressive disorder. When considering each clients belief system, the nurse should conclude which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

C. (Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts.)

A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? A. Assessing the clients pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurseclient relationship

A. (It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslows hierarchy of needs. This clients problems with oxygenation will take priority over assessing for current suicidal ideations.)

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourettes disorder? A. Antipsychotic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor medications

A. (The nurse should recognize that antipsychotic medications are effective in the treatment of Tourettes disorder. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Risperidone (Risperdal) has been shown to reduce symptoms by 21% to 61%.)

According to behavioral theory, the treatment of phobic symptoms should involve which action? A. The manipulation of the environment B. The use of desensitization C. The use of family therapy D. The uncovering of past events

B. (Systematic desensitization is a technique for assisting individuals to overcome their fear of a phobic stimulus. It is systematic in that there is a hierarchy of anxiety-producing events through which the individual progresses during therapy.)

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool

B. (The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.)

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug. B. I wont stop taking this medication abruptly, because there could be serious complications. C. I will not drink alcohol while taking this medication. D. I wont take extra doses of this drug because I can become addicted.

A. (The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.)

Which client statement demonstrates improvement in anger/aggression management? A. I realize I have a problem expressing my anger appropriately. B. I know I cant use physical force anymore, but I can intimidate someone with my words. C. Its bad to feel as angry as I feel. Im working on eliminating this poisonous emotion entirely. D. Because my wife seems to be the one to set me off, Ive decided to remain separated from her.

A. (The client is recognizing and taking responsibility for personal anger.)

Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge? A. I must observe you continually for 1 hour in order to keep you safe. B. Lets confer with the treatment team about the resources that you may need after discharge. C. You must have been very upset to do what you did today. D. Are you currently thinking about harming yourself?

B. (The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss client problems and needs.)

A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

A. (According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the clients laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.)

An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary? A. I hate all of you! B. My fingers are tingly. C. You wait until I tell my lawyer. D. I have a sinus headache.

B. (This statement may mean that the restraints are excessively tight and impeding circulation.)

A nurse should assess a patient taking a drug with anticholinergic properties for inhibited function of the: A. parasympathetic nervous system. B. sympathetic nervous system. C. reticular activating system. D. medulla oblongata.

A. (Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When acetylcholine action is inhibited by anticholinergic drugs, parasympathetic symptoms such as blurred vision, dry mouth, constipation, and urinary retention appear. The functions of the sympathetic nervous system, the reticular activating system, and the medulla oblongata are not affected by anticholinergics.)

A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this clients diagnosis? A. The client will name own body parts as separate from others by day 5. B. The client will establish a means of communicating personal needs by discharge. C. The client will initiate social interactions with caregivers by day 4. D. The client will not harm self or others by discharge.

A. (An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.)

A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

A. (A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.)

A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this clients plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

A. (A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.)

A nurse should recognize which intervention as most appropriate within a behavioral therapy program? A. A child is given a Popsicle for staying dry and clean. B. A child is put in time-out after soiling his or her undergarments. C. A child is allowed to remain in soiled undergarments. D. A child is taught the advantages of staying dry and clean.

A. (A stimulus that follows a behavior or response is called a reinforcing stimulus or reinforcer. The reward of a Popsicle is a reinforcer for the child staying dry and clean. This is an example of operant conditioning, a form of behavioral therapy.)

A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to find when assessing this client? A. A client feeling confident about achieving goals in life. B. A client who is aware of the need to set goals in life. C. A client who has mobilized personal and external resources. D. A client who begins to actively take control of his or her life.

A. (Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. In the growth stage, the individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being.)

A client states, My illness is so devastating, I feel like my life is on hold. The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates? A. Moratorium B. Awareness C. Preparation D. Rebuilding

A. (Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. The moratorium stage is identified by dark despair and confusion. It is called moratorium, because it seems that life is on hold.)

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. This medication will help you maintain your abstinence. B. This medication will cause uncomfortable symptoms if you combine it with alcohol. C. This medication will decrease the effect alcohol has on your body. D. This medication will lower your risk of experiencing a complicated withdrawal.

A. (Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.)

A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client? A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers

A. (Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions.)

A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, Im going to use a knotted shower curtain when no one is around. Which information would determine the nurses plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide.

A. (Clients who have specific plans are at greater risk for suicide.)

A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, You cant do this to me. Do you know who I am? Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation

A. (During a manic episode the clients mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury.)

The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: A. increased concentration of neurotransmitter in the synaptic gap. B. decreased concentration of neurotransmitter in the synaptic gap. C. destruction of receptor sites. D. limbic system stimulation.

A. (If the reuptake of a substance is inhibited, it accumulates in the synaptic gap and its concentration increases, permitting ease of transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with normal rather than depressed mood. The other options are not associated with blocking neurotransmitter reuptake.)

A third-grader feigns illness in order to avoid doing homework. The teacher recommends an educational program that uses a token economy. How should a school nurse explain a token economy to this childs parent? A. Your child will receive green tokens for completing homework that can be cashed in for desired rewards. B. Your child will receive red tokens when homework is incomplete and this will result in school suspension. C. Your child will receive a time out for each homework assignment not completed. D. Your child, with your assistance, will envision receiving rewards for completed homework.

A. (In a token economy, tokens are a form of contingency contracting in that tokens immediately reinforce appropriate behavior (completed homework) and are exchanged later for a desired reward.)

A mother states, You are old enough to clean your own bedroom. Later inspection finds the floor clear, but with everything stacked in a chair. The mother praises the child for clearing the floor. This is consistent with which technique of behavior modification? A. Shaping B. Extinction C. Stimulus generalization D. Reciprocal inhibition

A. (In shaping, behavior is molded in a desired direction by reinforcing each small step toward the desired behavior. The child is praised for clearing the floor, the first step toward cleaning the room.)

A client begins to smash furniture, cannot be talked down, and refuses medications. Which is the most appropriate nursing intervention? A. Call a violence code. B. Ask the ward clerk to put in a call for the physician. C. Place the client in seclusion. D. Place the client in four-point restraints.

A. (In this situation the nurse must have adequate, trained help to prevent injury to the client or staff. Calling a violence code will access this help.)

A nurse administers a medication that potentiates the action of GABA. Which finding would be expected? A. Reduced anxiety B. Improved memory C. More organized thinking D. Fewer sensory perceptual alterations

A. (Increased levels of GABA reduce anxiety, thus any potentiation of GABA action should result in anxiety reduction. Memory enhancement is associated with acetylcholine and substance P. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.)

A military vet who recently returned from active duty in a Middle Eastern country and suffers from PTSD states he will not allow the lab tech, who is Iranian, to draw his blood. The patient states Hell probably use a contaminated needle on me. Which of these is the most appropriate response by the nurse? A. Let me see if I can arrange for a different technician to draw your blood. B. Let me help you overcome your cultural bias by letting him draw your blood. C. There is no other technician, so youre just going to have to let him draw your blood. D. I dont think the technician is really Middle Eastern.

A. (Item A demonstrates acceptance of the patient and attempts to create a less threatening situation for the patient. Item B makes an unsubstantiated assumption about the patients biases. Item C will not contribute to the patients sense of control, and sense of comfort and control is important in managing symptoms of PTSD. Item D minimizes the patients concerns rather than responding empathically to them.)

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving: A. lithium (Lithobid) B. clozapine (Clozaril) C. fluoxetine (Prozac) D. venlafaxine (Effexor)

A. (Lithium is known to alter electrical conductivity, producing cardiac dysrhythmias, tremor, convulsions, polyuria, edema, and other symptoms of fluid and electrolyte imbalance. Patients receiving clozapine should be monitored for agranulocytosis. Patients receiving fluoxetine should be monitored for acetylcholine block. Patients receiving venlafaxine should be monitored for heightened feelings of anxiety.)

A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? A. Dopamine-blocking effects B. Anticholinergic effects C. Endocrine-stimulating effects D. Ability to stimulate spinal nerves

A. (Medication that blocks dopamine often produces disturbances of movement such as akathisia because dopamine affects neurons involved in both thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.)

A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions? A. Neuroleptic malignant syndrome B. Tardive dyskinesia C. Acute dystonia D. Agranulocytosis

A. (Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability.)

Arthur, who is diagnosed with obsessive-compulsive disorder, reports to the nurse that he cant stop thinking about all the potentially life threatening germs in the environment. What is the most accurate way for the nurse to document this symptom? A. Patient is expressing an obsession with germs. B. Patient is manifesting compulsive thinking. C. Patient is expressing delusional thinking about germs. D. Patient is manifesting arachnophobia of germs.

A. (Obsessions are unwanted, intrusive, repetitive thoughts. Compulsions are unwanted, repetitive behavior patterns in response to obsessive thoughts that are efforts to reduce anxiety.)

A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. I am sad most of the time and Ive felt this way for the last several years. B. I find myself preoccupied with death. C. Sometimes I hear voices telling me to kill myself. D. Im afraid to leave the house.

A. (Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.)

Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)? A. Grimacing and lip smacking B. Falling asleep in the chair and refusing to eat lunch C. Experiencing muscle rigidity and tremors D. Having excessive salivation and drooling

A. (TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine.)

A client diagnosed with obsessive-compulsive disorder states, I really think my future will improve because of my successful treatment choices. Im going to make my life better. Which guiding principle of recovery has assisted this client? A. Recovery emerges from hope. B. Recovery is person-driven. C. Recovery occurs via many pathways. D. Recovery is holistic.

A. (The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This client has internalized hope. This hope is the catalyst of the recovery process.)

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathetic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to societal norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains

A. (The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.)

A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

A. (The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.)

A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.

A. (The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression.)

A client diagnosed with panic disorder states, When an attack happens, I feel like I am going to die. Which is the most appropriate nursing reply? A. I know its frightening, but try to remind yourself that this will only last a short time. B. Death from a panic attack happens so infrequently that there is no need to worry. C. Most people who experience panic attacks have feelings of impending doom. D. Tell me why you think you are going to die every time you have a panic attack.

A. (The most appropriate nursing reply to the clients concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.)

A nursing instructor is teaching about donepezil (Aricept). A student asks, How does this work? Will this cure Alzheimers disease (AD)? Which is the appropriate instructor reply? A. This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. B. This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease. C. This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. D. This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.

A. (The most appropriate response by the instructor is to explain that donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of AD.)

A depressed client states, I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again. Which nursing response is appropriate? A. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors. B. Because biological factors are the sole cause of depression, medications will improve your mood. C. Environmental factors have been shown to exert the most influence in the development of depression. D. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment).

A. (The nurse should advise the client that medications are one treatment approach to address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression and the potential for psychological treatments to have a positive impact on biological factors.)

An adolescent client who was diagnosed with conduct disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. How should the nurse apply knowledge of conduct disorder to this clients situation? A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely. D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

A. (The nurse should apply knowledge of conduct disorder to determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.)

A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia

A. (The nurse should determine that an excessive fear of water is identified as aquaphobia, which is a natural environment type of phobia. Natural environmenttype phobias are fears about objects or situations that occur in the natural environment, such as a fear of heights or storms.)

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension

A. (The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.)

Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. B. Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, whereas clients diagnosed with avoidant personality disorder do not. C. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. D. Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, whereas clients diagnosed with avoidant personality disorder remain based in reality.

A. (The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection, which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.)

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

A. (The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considered as a treatment option. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur.)

A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness? A. Schizophrenia B. Depression C. Body dysmorphic disorder D. Parkinsons disease

A. (The nurse should expect that an increase in dopamine activity might play a significant role in the development of schizophrenia. Dopamine functions include regulation of emotions, coordination, and voluntary decision- making ability. Increased dopamine activity is also associated with mania.)

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

A. (The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.)

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse, Where do the voices come from? Which is the appropriate nursing reply? A. Your child has a chemical imbalance of the brain, which leads to altered thoughts. B. Your childs hallucinations are caused by medication interactions. C. Your child has too little serotonin in the brain, causing delusions and hallucinations. D. Your childs abnormal hormonal changes have precipitated auditory hallucinations.

A. (The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.)

A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. Taking multiple medications may lead to adverse interactions or toxicity. B. Age-related cognitive changes may lead to alterations in mental status. C. Lack of rigorous exercise may lead to decreased cerebral blood flow. D. Decreased social interaction may lead to profound isolation and psychosis.

A. (The nurse should identify that taking multiple medications may lead to adverse reactions or toxicity and put an older adult at risk for the development of delirium. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory.)

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

A. (The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.)

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

A. (The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.)

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week? A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

A. (The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals.)

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. Theres an alien growing in my liver. B. I see my dead husband everywhere I go. C. The IRS may audit my taxes. D. Im not going to eat my food. It smells like brimstone.

A. (The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the persons intelligence or cultural background.)

A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

A. (The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.)

A lonely, depressed divorce has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individuals situation? A. The individual is experiencing psychological addiction. B. The individual is experiencing physical addiction. C. The individual is experiencing substance addiction. D. The individual is experiencing social addiction.

A. (The nurse should use the term psychological addiction to best describe this clients situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.)

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. B. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. C. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. D. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

A. (The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food, followed by purging.)

A client who has been diagnosed with bipolar I disorder states, God has taught me how to decode the Bible. A nurse should anticipate that which combination of medications would be ordered to address this clients symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal)

A. (The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia.)

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? A. The pharmacological action of Ritalin causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.

A. (The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD.)

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others

A. (The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior.)

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

A. (The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.)

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment

A. (The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.)

Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, Do you ever think about killing yourself? B. Ask client, Please rate your mood on a scale from 1 to 10. C. Establish a trusting nurseclient relationship. D. Apply the nursing process to the planning of client care.

A. (The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan.)

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder. B. Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder. C. Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks. D. Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.

A. (The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.)

A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this childs behavior. Which student response indicates an appropriate evaluation of the situation? A. This childs behavior must be evaluated according to developmental norms. B. This child has symptoms of attention deficit hyperactivity disorder. C. This child has symptoms of the early stages of autistic disorder. D. This childs behavior indicates possible symptoms of oppositional defiant disorder.

A. (The students evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.)

A client diagnosed with bipolar disorder states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. What should be the priority nursing action? A. Assess the clients vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.

A. (When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The clients statement of Im thirsty and Im burning up could be a symptom of either infection or dehydration and must be assessed.)

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

A. (Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.)

A patient admitted to the hospital with PTSD is ordered the following medications. Which of these medications has a direct use in treating symptoms that are common in PTSD? Select all that apply. A. Alprazolam B. Propanolol C. Colace D. Dulcolax

A.B. (Alprazolam is an antianxiety agent and anxiety symptoms are common in PTSD. Propanolol is an antihypertensive medication and evidence has demonstrated its effectiveness in treating symptoms of PTSD, including nightmares, intrusive recollections, and insomnia. The last two medications are used to treat constipation, and this symptom is not directly related to PTSD.)

A patients wife reports to the nurse that she was told her husbands PTSD may be related to cognitive problems. She is asking the nurse to explain what that means. Which of the following are accurate statements about the cognitive theory as it applies to PTSD? Select all that apply. A. People are vulnerable to trauma-related disorders when their fundamental beliefs are invalidated. B. Cognitive theory addresses the importance of how people think (or cognitively appraise) events. C. Dementia is a common symptom of PTSD. D. Amnesia is the biggest cognitive problem in PTSD and is the primary cause of trauma-related disorders.

A.B. (Both A and B address aspects of cognitive theory and its relevance in PTSD. Dementia includes cognitive symptoms but is not a symptom of PTSD. Amnesia does not cause PTSD but is a symptom of PTSD.)

Joe, a patient being treated for PTSD, tells the nurse that his therapist is recommending cognitive therapy. He asks the nurse how thats supposed to help his nightmares. Which of these responses by the nurse provides accurate information about the benefits of this type of therapy? Select all that apply. A. The nightmares may be related to troubling thoughts and feelings; cognitive therapy will help you explore and modify those thoughts and feelings. B. It is designed to help you cope with anxiety, anger, and other feelings that may be related to your symptoms. C. It is designed to repeatedly expose you to the trauma you experienced so you can regain a sense of safety. D. Once you learn to repress these troubling feelings, the nightmares should cease.

A.B. (Both A and B are desired outcomes in cognitive therapy. Item C more aptly describes prolonged exposure therapy. D is incorrect because exploration and awareness (rather than repression) are fundamental to cognitive therapy.)

Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age. D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant.

A.B. (It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.)

23. Which of the following symptoms should a nurse associate with increased levels of thyroid-stimulating hormone (TSH) in a newly admitted client? Select all that apply. A. Depression B. Fatigue C. Increased libido D. Mania E. Hyperexcitability

A.B. (The nurse should associate depression and fatigue with increased levels of TSH. TSH is only increased when thyroid levels are low, as in the diagnosis of hypothyroidism. In addition to depression and fatigue, other symptoms such as decreased libido, memory impairment, and suicidal ideation are also associated with chronic hypothyroidism.)

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? Select all that apply. A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

A.B. (The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and treating bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.)

A military veteran is being assessed for outpatient therapy after he reports having problems at home and at work. Which of the symptoms that he describes are commonly associated with PTSD? Select all that apply. A. Ive been drinking and smoking pot daily. B. Ive been having trouble sleeping and I think Ive been having nightmares but I cant remember them. C. I slapped my wife when she was trying to hug me. D. Ive been having intense pain in the leg where I sustained a combat wound.

A.B.C. (Common symptoms associated with PTSD include substance abuse, sleep disturbances, nightmares, and aggression. Whereas the combat exposure and wounding could be described as traumas, the patients complaint of pain requires further physical assessment rather than assuming this symptom is related to PTSD.)

Joshua recently moved into a dormitory to begin his freshman year in college. He was reprimanded by the dormitory supervisor for not properly disposing of food items and responded by throwing all of his belongings from a second story window while shouting obscenities. The campus police escorted him to campus health services, where he was diagnosed with an Adjustment Disorder with Disturbance of Conduct. Which of the following items in Joshuas history predispose him to this disorder? Select all that apply. A. Joshua reports that he doesnt have any friends in the dormitory. B. Joshuas family currently lives out of the country and are often difficult to reach. C. Joshua was notified the same day that he would have to withdraw from one of his classes because he didnt have the prerequisite credits needed to register for the class. D. Joshua has a higher than average GPA and is a member of The National Honor Society.

A.B.C. (Items A and B may suggest lack of available support systems, which is identified as a predisposing factor for Adjustment Disorders. Item C presents evidence of another stressor occurring in proximity to the reprimand from the dormitory supervisor, which may also predispose to the development of an Adjustment Disorder.)

After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply. A. I cant believe this is happening. B. If only I had been more understanding. C. How dare he do this to me! D. Im just going to have to accept that he was gay. E. Well, that was a selfish thing to do.

A.B.C. (Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father. The last two possible responses suggest acceptance and understanding. It is far more common for survivors of suicide to have a sense of feeling wounded and as if they will never get over it.)

Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2,500 to 3,000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1,500 mL per day.

A.B.C. (The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels.)

A client who has been diagnosed with a phobic disorder asks the nurse if there are any medications that would be beneficial in treating phobic disorders. Which of the following would be accurate responses by the nurse? Select all that apply. Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017) 229 A. Some antianxiety agents have been successful in treating social phobias. B. Some antidepressant agents have been successful in diminishing symptoms of agoraphobia and social anxiety disorder (social phobia). C. Specific phobias are generally not treated with medication unless accompanied by panic attacks. D. Beta-blockers have been used successfully to treat phobic responses to public performance.

A.B.C.D. (All of the listed pharmacological treatments are evidence-based treatments for phobic disorders.)

Which of the following has the SAMHSA described, as major dimensions of support for a life of recovery? Select all that apply. A. Health B. Community C. Home D. Religious affiliation E. Purpose

A.B.C.E. (SAMHSA suggests that a life in recovery is supported by four major dimensions: health, home, purpose, and community. Religious affiliation is not included in the listed dimensions.)

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. Ill have to let my surgeon know about this medication before I have my cholecystectomy. B. Guess I will have to give up my glass of red wine with dinner. C. Ill have to be very careful about reading food and medication labels. D. Im going to miss my caffeinated coffee in the morning. E. Ill be sure not to stop this medication abruptly.

A.B.C.E. (The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions.)

A nurse uses the commitments of the Tidal Model of Recovery in psychiatric nursing practice. Which of the following nursing actions reflect the use of the Develop Genuine Curiosity commitment? Select all that apply. A. The nurse expresses interest in the clients story. B. The nurse asks for clarification of certain points. C. The nurse encourages the client to speak his own words in his own unique way. D. The nurse assists the client to unfold the story at his or her own rate. E. The nurse provides the clients with copies of all documents relevant to care.

A.B.D. (Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Develop Genuine Curiosity commitment, by expressing interest, asking for clarification, and assisting the client to unfold the story at his or her own rate.)

Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply. A. I am easily manipulated and need to work on this prior to caring for these clients. B. Because of my fathers alcoholism, I need to examine my attitude toward these clients. C. Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights. D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training. E. I can fix clients diagnosed with substance use disorders as long as I truly care about them.

A.B.D. (The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurses ability to establish therapeutic relationships with these clients. A nurse who adopts the attitude that he or she can fix another person may be struggling with codependency issues.)

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply. A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

A.B.D.E. (The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.)

Which of the following information should a nurse include when explaining causes of anorexia nervosa to a client? Select all that apply. A. There is a possible correlation between abnormal secretion of growth hormone and anorexia nervosa. B. There is a possible correlation between antidiuretic hormone levels and anorexia nervosa. C. There is a possible correlation between low levels of gonadotropin and anorexia nervosa. D. There is a possible correlation between increased levels of prolactin and anorexia nervosa. E. There is a possible correlation between altered levels of oxytocin and anorexia nervosa.

A.C. (The nurse should explain to the client that there is a possible correlation between anorexia nervosa and decreased levels of growth hormones and gonadotropin. Anorexia nervosa has also been correlated with increased cortisol levels.)

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? Select all that apply. A. A diet rich in protein will promote hepatic healing. B. This condition leads to a rise in serum ammonia, resulting in impaired mental functioning. C. In this condition, blood accumulates in the abdominal cavity. D. Neomycin and lactulose are used in the treatment of this condition. E. This condition is caused by the inability of the liver to convert ammonia to urea.

A.C. (The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing or that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia by means of neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion.)

A patient is admitted to the community mental health center for outpatient therapy with a diagnosis of Adjustment Disorder. Which of the following subjective statements by the patient support this diagnosis? Select all that apply. A. I was divorced 3 months ago and I cant seem to cope. B. I was a victim of date rape 15 years ago when I was in college. C. My partner came home last week and told me he just didnt love me anymore. D. I failed one of my classes last month and I cant get motivated to register for my next semester.

A.C.D. (A diagnosis of Adjustment Disorder is appropriate when the stressors are related to relational conflict, where there are significant emotional or behavioral symptoms, and when the response occurs within 3 months after the onset of the stressor (and persists no longer than 6 months). Item B would be more aptly described as a traumatic event.)

A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

A.C.D. (Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post- menses)

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

B. (A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.)

A patient who is being seen in the community mental health center for PTSD is being considered for EMDR (Eye Movement Desensitization and Reprocessing) therapy. The nurse is being asked to conduct an assessment to validate the patients appropriateness for this treatment. Which of the following pieces of data, collected by the nurse, are most important to document when determining appropriateness for treatment with EMDR? Select all that apply. A. The patient has a history of a seizure disorder. B. The patient has a history of ECT. C. The patient reports suicidal ideation with a plan. D. The patient has been using alcohol in increasing quantities over the last 3 months.

A.C.D. (Items A, C, and D are all factors that would contraindicate the use of EMDR. A history of ECT is not directly relevant in determining appropriateness for EMDR.)

Which of the following symptoms should a nurse expect to assess in a client experiencing elevated levels of thyroid hormone? Select all that apply. A. Emotional lability B. Depression C. Insomnia D. Restlessness E. Apathy

A.C.D. (The nurse should assess the client with an elevated level of thyroid hormone for evidence of emotional lability, insomnia, and restlessness. Elevated levels of thyroid hormone indicate a diagnosis of hyperthyroidism or Graves disease, which is also associated with the symptoms of irritability, anxiety, and weight loss.)

A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply. A. In the Middle Ages, suicide was viewed as a selfish and criminal act. B. During the Roman Empire, suicide was followed by incineration of the body. C. Suicide was an offense in ancient Greece, and a common-site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically. E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

A.C.D. (These are true historical facts about suicide and should be included in the students study guide.)

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this clients symptoms? Select all that apply. A. Encourage the client to recognize the signs of escalating anxiety. B. Encourage the client to avoid any situation that causes stress. C. Encourage the client to employ newly learned relaxation techniques. D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. E. Encourage the client to avoid caffeinated products.

A.C.D.E. (Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.)

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply. A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

A.C.E. (The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.)

A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply. A. Acknowledge the clients behavior. B. Initiate forced medication protocol. C. Assist the client to a quiet area. D. Initiate confinement measures. E. Speak with a soft and calming voice.

A.C.E. (The nurse should remain calm when dealing with an angry client. It is important to acknowledge the clients behavior and assist the client to a less stimulating environment)

A nurse who works on an inpatient psychiatric unit is working on developing a treatment plan for a patient admitted with PTSD. The patient, a military veteran, reports that sometimes he thinks he sees bombs exploding and the enemy rushing toward him. He has had aggressive outbursts and was hospitalized after assaulting a coworker during one of these episodes. Which of these interventions by the nurse are evidence-based responses? Select all that apply. A. Collaborate with the patient about how he would like staff to respond when he has episodes of re- experiencing traumatic events. B. Tell the patient it is not appropriate to hit other patients or staff and if that occurs he will have to be discharged from the hospital. C. Contact the doctor and recommend that the patient be ordered an antipsychotic medication. D. Refer the patient to a support group with other military veterans.

A.D. (Collaborating with the patient demonstrates an environment of mutual respect and is helpful in establishing a trusting relationship. Both of these are identified as essential in effective treatment of PTSD. Evidence also supports that a group with other people who have experienced similar traumas is helpful in reducing the sense of isolation that some people with PTSD experience. Items B and C are incorrect since they both reflect an inaccurate understanding of the dynamics of PTSD)

A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? Select all that apply. A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability

A.D.E. (The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.)

A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu C. A client diagnosed with conduct disorder who is demanding special attention from staff D. A client diagnosed with attention deficit disorder who has a history of self-mutilation

B. (A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately.)

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. Well go to the day room when you are ready for group. B. Ill walk with you to the day room. Group is about to start. C. It must be difficult for you to attend group when you feel so bad. D. Let me tell you about the benefits of attending this group.

B. (A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.)

22. Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. I will limit my intake of fluids daily. B. I will maintain normal salt intake. C. I will take Lithobid on an empty stomach. D. I will increase my caloric intake to prevent weight loss.

B. (A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain.)

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client? A. Im not going to use heroin ever again. I know Ive got the willpower to do it this time. B. I cannot control my use of heroin. Its stronger than I am. C. Im going to get all my children back. They need their mother. D. Once I deal with my childhood physical abuse, recovery should be easy.

B. (A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over a substance)

Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter

B. (A prior history of assault is the most widely recognized risk factor for client violence.)

A client presents in the emergency department with complaints of overwhelming anxiety. Which of the following is a priority for the nurse to assess? A. Risk for suicide B. Cardiac status C. Current stressors D. Substance use history

B. (Although all of the listed aspects of assessment are important, the priority is to evaluate cardiac status since a person having an MI, CHF, or mitral valve prolapse can present with symptoms of anxiety.)

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

B. (Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization.)

Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017) 135 B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship.

B. (Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, and measureable and contain a time frame.)

Which mental illness should a nurse identify as being associated with a decrease in prolactin hormone level? A. Major depression B. Schizophrenia C. Anorexia nervosa D. Alzheimers disease

B. (Although the exact mechanism is unknown, there may be some correlation between decreased levels of the hormone prolactin and the diagnosis of schizophrenia. Some studies have shown an inverse relationship between prolactin concentrations and symptoms of schizophrenia.)

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.

B. (An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.)

A client states, I have come to the conclusion that this disease has not paralyzed me. The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates? A. Moratorium B. Awareness C. Preparation D. Rebuilding

B. (Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. In the awareness stage, the individual comes to a realization that a possibility for recovery exists. Andresen and associates state, It involves an awareness of a possible self other than that of sick person: a self that is capable of recovery.)

A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? A. Your grieving will subside within 1 year; until then I recommend antidepressants. B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area. C. The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them. D. Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone.

B. (Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work.)

A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose? A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions

B. (Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system, leading to respiratory arrest and death.)

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. I cannot drink any alcohol with this medication. B. It is going to take 2 to 3 weeks in order for me to begin to feel better. C. This drug causes physical dependence, and I need to strictly follow doctors orders. D. I cant take this medication with food. It needs to be taken on an empty stomach.

B. (BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.)

A newly admitted client diagnosed with major depressive disorder states, I have never considered suicide. Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. There is nothing to worry about. We will handle it together. B. Bringing this up is a very positive action on your part. C. We need to talk about the things you have to live for. D. I think you should consider all your options prior to taking this action.

B. (By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.)

A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability

B. (Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic.)

A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

B. (Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.)

The nurse observes a clients escalating anger. The client begins to pace the hall and shouts, You all better watch out. Im going to hurt anyone who gets in my way. Which should be the priority nursing intervention? A. Calmly tell the client, Staff will help you to control your impulse to hurt others. B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, You will need to be medicated and secluded.

B. (During an emergent situation on an inpatient unit, the nurses priority action should be to keep all clients safe by removing them from the area of conflict.)

A clients spouse asks, What evidence supports the possibility of genetic transmission of bipolar disorder? Which is the best nursing reply? A. Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors. B. Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder. C. Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress. D. More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds.

B. (Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great.)

A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. Anger is physiological arousal. B. Anger and aggression are essentially the same. C. Anger expression is a learned response. D. Anger is not a primary emotion.

B. (Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different.)

Jane presents in the Emergency Department with a friend, who reports that Jane has been sitting in her apartment staring off into space and doesnt seem interested in doing anything. During the assessment Jane reveals, with little emotion, that she was raped 4 months ago. Which of these is the most appropriate interpretation of Janes lack of emotion? A. Jane is probably hearing voices telling her to be emotionless. B. Jane is experiencing numbing of emotional response, which is a common symptom of PTSD. C. Jane is trying to be secretive, and lying is a common symptom in PTSD. D. Jane is currently re-experiencing the traumatic event and is having a dissociative episode.

B. (General numbing of emotional response is a common symptom of PTSD. Items A and D are not the most appropriate interpretations because the data are inadequate to make that inference. Item C is incorrect; lying is not a common symptom in PTSD.)

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. I cant stop my sexual urges. They have led me to numerous affairs. B. Im the worlds most perceptive attorney. C. My wife is distraught about my overspending. D. The FBI is out to get me.

B. (Grandiosity is defined as a belief that personal abilities are better than anyone elses. This client is experiencing delusions of grandeur, which are commonly experienced in mania.)

In assessing a client with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

B. (If large doses of a central nervous system (CNS) depressant (such as Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.)

Parents of a 3-year-old have noticed an improvement in behavior because of using a time out behavioral approach. What aspect of time out therapy may be responsible for this childs improved behavior? A. Negative reinforcement discourages maladaptive behavior. B. Positive reinforcement is removed. C. Covert sensitization is being applied. D. Reciprocal inhibition is eliminated.

B. (In a time out, the positive reinforcement of attention is removed from the child during inappropriate behavior.)

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

B. (Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.)

A nursing instructor is teaching about components present in the recovery process, as described by Andresen and associates, which led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed? A. A client has a better chance of recovery if he or she truly believes that recovery can occur. B. If a client is willing to give the responsibility of treatment to the health-care team, he or she is likely to recover. C. A client who has a positive sense of self and a positive identity is likely to recover. D. A client has a better chance of recovery if he or she has purpose and meaning in life.

B. (In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being.)

An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. The nurse should initially implement which nursing action? A. Redirect the client to activities to decrease stress. B. Explain the unit rules and consequences of breaking the rules. C. Place the client on close observation to insure a trusting relationship. D. Administer an anti-anxiety medication.

B. (It is important for the nurse to initially explain the unit rules and consequences of breaking the rules. It is imperative that consequences of rule infractions are explained early in treatment to avoid misunderstanding and manipulation.)

Brandy is an 18-year-old being treated in the Community Mental Health Clinic for an adjustment disorder after receiving news of her parents impending divorce. While talking about her feelings she becomes angry and starts shouting and crying. She screams, I wish they would both die! Which of these is the most appropriate response by the nurse at this point? A. Contact the parents and the police to report that Brandy is expressing homicidal ideation. B. Encourage Brandy to talk more about her anger. C. Instruct Brandy that its okay to cry but that it is not acceptable to talk that way about her parents. D. Assess Brandy for suicidal ideation.

B. (It is important in treating patients with adjustment disorders to allow them to express anger. Item C discourages the patient from expressing anger. Items A and D would be premature, since there is inadequate evidence to warrant those responses.)

Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? A. Place a hand on the clients shoulder and state, I will help you to your room. B. Slowly and matter-of-factly state, I am your nurse and I will show you to your room. C. Firmly set limits by stating, If your behavior does not improve you will be secluded. D. Smile and state, I am your nurse. When do you want to go to your room?

B. (It is important to maintain an unemotional tone of voice when dealing with a hostile client. The client might misinterpret touch and become violent.)

A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works? A. Ritalins sedation side effect assists children by decreasing their energy level. B. How Ritalin works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD. C. Ritalin helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapse. D. Ritalin decreases hyperactivity by increasing serotonin levels.

B. (It is unknown how Ritalin works, but even though it is a stimulant, it does decrease hyperactivity in individuals diagnosed with ADHD.)

Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards? A. The patient must be let out of restraint. B. A physician or other licensed independent practitioner must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing.

B. (Joint Commission (JCAHO) standards require that a physician or other licensed independent practitioner conduct an in-person evaluation of the client within 1 hour of the initiation of restraint.)

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

B. (Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.)

What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

B. (Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.)

An adolescent comes from a dysfunctional family where physical and verbal abuse prevails. At school this adolescent bullies and fights with classmates. According to principles of behavior therapy, what is the probable source of this behavior? A. Shaping B. Modeling C. Premack principle D. Reciprocal inhibition

B. (Modeling is the learning of new behaviors by imitating the behaviors of others. This adolescent, witnessing physical and verbal abuse in the home, models this behavior in school.)

A nursing instructor is teaching about the behavior technique of modeling. When asked to give an example of this behavioral intervention, which student statement meets the learning objective? A. A child is first rewarded for using a spoon to eat and then rewarded for using a fork, and finally rewarded for cutting food with a knife. B. An adolescent imitates Dad by using and caring for tools appropriately. C. A client and therapist agree to conditions of therapy, stating explicitly in writing the behavior change that is desired. D. A mother tells her child that television can be watched only after homework is completed.

B. (Modeling refers to the learning of new behaviors by imitating the behavior of others.)

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients diagnosed with amnesic disorders? A. Neurocognitive disorders involve disorientation that develops suddenly, whereas amnestic disorders develop more slowly. B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not. C. Neurocognitive disorders include the symptom of confabulation, whereas amnestic disorders do not. D. Both neurocognitive disorders and profound amnesia typically share the symptom of disorientation to place, time, and self.

B. (Neurocognitive disorders involve impairment of abstract thinking and judgment. Amnestic disorders are characterized by an inability to learn new information and to recall previously learned information, with no impairment in higher cortical functioning or personality change.)

A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of suffering in silence. Which underlying cause of this clients personality disorder should a nurse recognize? A. Nurturance was provided from many sources, and independent behaviors were encouraged. B. Nurturance was provided exclusively from one source, and independent behaviors were discouraged. C. Nurturance was provided exclusively from one source, and independent behaviors were encouraged. D. Nurturance was provided from many sources, and independent behaviors were discouraged.

B. (Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.)

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, Im feeling a lot better, so you can stop watching me. I have taken up too much of your time already. Which is the best nursing reply? A. I really appreciate your concern but I have been ordered to continue to watch you. B. Because we are concerned about your safety, we will continue to observe you. C. I am glad you are feeling better. The treatment team will consider your request. D. I will forward you request to your psychiatrist because it is his decision.

B. (Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.)

A nurse instructs a patient taking a drug that inhibits 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

B. (Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.)

Six months after her husband and children were killed in a car accident, a client is diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which study perspective? A. The study of neuroendocrinology B. The study of psychoimmunology C. The study of diagnostic technology D. The study of neurophysiology

B. (Psychoimmunology is the branch of medicine that studies the effects of social and psychological factors on the functioning of the immune system. Studies of the biological response to stress hypothesize that individuals become more susceptible to physical illness following exposure to stressful stimuli.)

A client is diagnosed with an anxiety disorder. The nurse counselor recommends intervention with the behavioral technique of reciprocal inhibition. The client asks, Whats that? Which is the most appropriate nursing reply? A. At the beginning of this intervention, a contract will be drawn up explicitly stating the behavior change agreed upon. B. By introducing an adaptive behavior that is mutually exclusive to your maladaptive behavior, we will expect subsequent behavior to improve. C. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety. D. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.

B. (Reciprocal inhibition decreases or eliminates an undesired behavior by introducing a more adaptive behavior that is incompatible with the undesired behavior.)

For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions.

B. (Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves or others)

A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to the SAMHSA, which dimension of recovery is supporting this client? A. Health B. Home C. Purpose D. Community

B. (SAMHSA describes the dimension of Home as a stable and safe place to live.)

A nursing instructor is teaching about the guiding principles of the recovery model, as described by the SAMHSA. Which student statement indicates that further teaching is needed? A. Recovery occurs via many pathways. B. Recovery emerges from strong religious affiliations. C. Recovery is supported by peers and allies. D. Recovery is culturally based and influenced

B. (SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. Recovery emerges from hope, but affiliation with any particular religion would have little bearing on the recovery process.)

During a sleep study, a delta rhythm has been recorded for a client experiencing sleep apnea. The nurse recognizes that which characteristic is associated with this rhythm, and what stage of sleep activity would be documented? A. Delta rhythm is a period of dozing, occurring in stage 1 of sleep activity. B. Delta rhythm is a period of deep and restful sleep, occurring in stage 3 of sleep activity. C. Delta rhythm is a period of relaxed waking, occurring in stage 0 of sleep activity. D. Delta rhythm is a period of dreaming, occurring in stage 2 of sleep activity.

B. (Stage 3delta rhythm is a period of deep and restful sleep. Muscles are relaxed, heart rate and blood pressure fall, and breathing slows. No eye movement occurs.)

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the clients restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order

B. (The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children.)

A nurse maintains a clients confidentiality, addresses the client appropriately, and does not discriminate on the basis of gender, age, race, or religion. Which guiding principle of recovery has this nurse employed? A. Recovery is culturally based and influenced. B. Recovery is based on respect. C. Recovery involves individual, family, and community strengths and responsibility. D. Recovery is person-driven.

B. (The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope;recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This nurse accepts and appreciates clients who are affected by mental health and substance use problems. This nurse protects the rights of clients and does not discriminate against them.)

A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? A. The goal of recovery is improved health and wellness. B. The goal of recovery is expedient, comprehensive behavioral change. C. The goal of recovery is the ability to live a self-directed life. D. The goal of recovery is the ability to reach full potential.

B. (The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental health disorders and substance use disorders as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Change in recovery is not an expedient process. It occurs incrementally over time.)

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. You are very disrespectful. You need to learn to control yourself. B. I understand that you are angry, but this behavior will not be tolerated. C. What behaviors could you modify to improve this situation? D. What anti-personality-disorder medications have helped you in the past?

B. (The appropriate nursing statement is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the treatment of a personality disorder.)

Which is the priority focus of recovery models? A. Empowerment of the health-care team to bring their expertise to decision-making B. Empowerment of the client to make decisions related to individual health care C. Empowerment of the family system to provide supportive care D. Empowerment of the physician to provide appropriate treatments

B. (The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care.)

A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess? A. The client expresses feeling blue most of the time. B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.

B. (The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder.)

A nursing instructor is teaching about the monoamine category of neurotransmitters. Which student statement indicates that learning about the function of norepinephrine has occurred? A. Norepinephrine functions to regulate movement, coordination, and emotions. B. Norepinephrine functions to regulate mood, cognition, and perception. C. Norepinephrine functions to regulate arousal, libido, and appetite. D. Norepinephrine functions to regulate pain, inflammatory response, and wakefulness.

B. (The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, and cardiovascular function. Norepinephrine has also been implicated in certain mood disorders such as depression and mania, anxiety states, and schizophrenia.)

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this clients safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.

B. (The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the clients safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.)

After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement? A. I should expect to feel better in a couple of days. B. Ill call my doctor immediately if I experience any diarrhea or ringing in my ears. C. If I forget a dose, I can double the dose the next time I take this drug. D. I need to restrict my intake of any food containing salt.

B. (The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.)

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. C. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. D. They pay particular attention to details, which can frustrate the development of relationships.

B. (The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.)

Which cerebral structure should a nursing instructor describe to students as the emotional brain? A. The cerebellum B. The limbic system C. The cortex D. The left temporal lobe

B. (The limbic system is often referred to as the emotional brain. The limbic system is largely responsible for ones emotional state and is associated with feelings, sexuality, and social behavior.)

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg daily, for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. High doses of tricyclic medications will be required for effective treatment of OCD. B. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD. C. The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia. D. The dosage of Luvox is outside the therapeutic range and needs to be questioned.

B. (The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.)

Using a behavioral approach, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues.

B. (The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.)

A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, Should I seek psychiatric help for my mother? Which is an appropriate nursing reply? A. My mother also worries unnecessarily. I think it is part of the aging process. B. Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning. C. From what you have told me, you should get her to a psychiatrist as soon as possible. D. Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.

B. (The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.)

A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, Im such a terrible mother. What did I do to cause this? Which nursing reply is most appropriate? A. Researchers really dont know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored. B. Poor parenting doesnt cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control. C. Research has shown that the mother appears to play a greater role in the development of this disorder than the father. D. Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?

B. (The most appropriate reply by the nurse is to explain to the parent that autism spectrum disorder is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism spectrum disorder occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys.)

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

B. (The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.)

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

B. (The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the clients needs and maintain a calm attitude when dealing with agitated behavior.)

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, Have you ever felt that certain objects or persons have control over your behavior? The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

B. (The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the clients behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.)

A nurse evaluates a clients patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30- minute period. Which is the best rationale for assessing this client for substance use disorder? A. Narcotic pain medication is contraindicated for all clients with active substance-use problems. B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B. (The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessens the clients response to another drug.)

A client diagnosed with schizophrenia tells a nurse, The Shopatouliens took my shoes out of my room last night. Which is an appropriate charting entry to describe this clients statement? A. The client is experiencing command hallucinations. B. The client is expressing a neologism. C. The client is experiencing a paranoia. D. The client is verbalizing a word salad.

B. (The nurse should describe the clients statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.)

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

B. (The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.)

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body

B. (The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.)

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder

B. (The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.)

A client is admitted to a psychiatric unit with the diagnosis of catatonic schizophrenia. Which of the clients neurotransmitters should a nurse expect to be elevated? A. Serotonin B. Dopamine C. Gamma-aminobutyric acid (GABA) D. Histamine

B. (The nurse should expect that elevated dopamine levels might be an attributing factor to the clients current level of functioning. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability.)

A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this clients assessment data, which diagnosis would the nurse expect the physician to assign? A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimers disease

B. (The nurse should expect that this client would be diagnosed with vascular neurocognitive disorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abrupt onset. This disease often occurs in a fluctuating pattern of progression.)

Which finding would be most likely in a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The childs mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The childs mother and father have an inconsistent parenting style.

B. (The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child diagnosed with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.)

A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear? A. Your spouse may be unable to resolve internal conflicts, which result in projected anxiety. B. Your spouse may be experiencing a distorted and unrealistic appraisal of the situation. C. Your spouse may have a genetic predisposition to overreacting to potential danger. D. Your spouse may have high levels of brain chemicals that may distort thinking.

B. (The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.)

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor add that to my medications? Which is an appropriate nursing reply? A. This combination of drugs can lead to delirium tremens. B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis. C. Thats a good idea. There have been good results with the combination of these two drugs. D. The only disadvantage would be the exorbitant cost of the MAOI.

B. (The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.)

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the clients focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

B. (The nurse should focus on the clients feelings rather than attempt to change the clients delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.)

A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

B. (The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.)

A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents? A. If one dose of Ritalin is missed, double the next dose. B. Administer Ritalin to the child after breakfast. C. Administer Ritalin to the child just prior to bedtime. D. A side effect of Ritalin is decreased ability to learn.

B. (The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.)

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

B. (The nurse should note escalating behaviors and intervene immediately to maintain this clients safety. Early intervention may prevent an aggressive response and keep the client and others safe.)

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? A. Antecubital bruising B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

B. (The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.)

A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the clients positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

B. (The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.)

Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders? A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life

B. (The nurse should reinforce positive actions to encourage repetition of desired behaviors when caring for children diagnosed with a disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.)

A college student has quit attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

B. (The nursing diagnosis that must be prioritized in this situation is risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicate a potential for violence, and this potential safety issue should be prioritized.)

An instructor is teaching nursing students about neurotransmitters. Which term best explains the process of how neurotransmitters released into the synaptic cleft may return to the presynaptic neuron? A. Regeneration B. Reuptake C. Recycling D. Retransmission

B. (The nursing instructor should best explain that the process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is by reuptake. Reuptake is the process by which neurotransmitters are stored for reuse.)

A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. These clients do not recognize that their fear is excessive, and they rarely seek treatment. B. These clients have overwhelming symptoms of panic when exposed to the phobic stimulus. C. These clients experience symptoms that mirror a cerebrovascular accident (CVA). D. These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.

B. (The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response.)

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesperson to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership.

B. (The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors)

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred? A. This disorder is more prevalent in the lower socioeconomic groups. B. This disorder is more prevalent in the higher socioeconomic groups. C. This disorder is equally prevalent in all socioeconomic groups. D. This disorders prevalence cannot be evaluated on the basis of socioeconomic groups.

B. (The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder.)

Major Smith, who is being treated for PTSD symptoms following a course of military duty, reports, I think I was in denial about even having PTSD. I thought I was just having trouble sleeping. Which of these is an accurate evaluation of the patients comments? A. The patient is still in denial and unable to recognize that he is having flashbacks rather than insomnia. B. The patient is beginning to recognize stages of grieving and reevaluating his symptoms. C. The patient is beginning to recognize that he may be at risk for suicide. D. The patient is trying to avoid discussing symptoms of PTSD.

B. (The patient is expressing recognition that he was in denial, which is a stage of grieving. It is not uncommon for people to recognize that they are having troubling symptoms but not immediately recognize this as PTSD.)

A patient hospitalized with a mood disorder has an elevated unstable mood, aggressiveness, agitation, talkativeness, and irritability. A nurse begins care planning based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): A. anticholinergic. B. mood stabilizer C. psychostimulant D. antidepressant

B. (The symptoms describe a manic attack. Mania is effectively treated by the antimanic drug lithium and selected anticonvulsants such as carbamazepine, valproic acid, and lamotrigine. No drugs from the other classifications listed are effective in the treatment of mania.)

A client has the following symptoms: preoccupation with imagined defect, verbalizations that are out of proportion to actual physical abnormalities, and numerous visits to plastic surgeons to seek relief. Which nursing diagnosis would best describe the problems evidenced by these symptoms? A. Ineffective coping B. Disturbed body image C. Complicated grieving D. Panic anxiety

B. (The symptoms presented describe the DSM-5 diagnosis of body dysmorphic disorder, and the related nursing diagnosis is disturbed body image.)

A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L

B. (The therapeutic level of lithium carbonate is 1.0 to 1.5 mEq/L for acute mania and 0.6 to 1.2 mEq/L for maintenance therapy. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7 mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death.)

A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, How will we know if someone may get violent? Which is the most appropriate reply by the nursing instructor? A. You cant really say for sure. There are limited indicators of potential violence. B. Certain behaviors indicate a potential for violence. They are labeled as a prodromal syndrome and include rigid posture, clenched fists, and raised voice. C. Any client can become violent, so it is best to be aware of your surroundings at all times. D. When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence.

B. (These behaviors have been identified as predictors of violent behavior)

After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care? A. Have there been any changes in appetite or sleep? B. How often is your spouse left alone? C. Has your spouse been following a diet and exercise program consistently? D. How would you characterize your relationship with your spouse?

B. (This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.)

A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death among the elderly. D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

B. (This factual information should be included in the nursing instructors teaching plan. An expressed desire to die is not normal in any age group.)

A patient being treated for symptoms of PTSD following a shooting incident at a local elementary school reports I feel like theres no reason to go on living when so many others died. Which of these is the most appropriate response by the nurse at this juncture? A. Youve got lots of reasons to go on living B. Are you having thoughts of hurting or killing yourself? C. Youre just experiencing survivor guilt. D. There must be something that gives you hope.

B. (This patient is expressing hopelessness, and it is a priority to assess for suicide ideation in these circumstances. Items A and D minimize the patients experience of feeling hopelessness. Item C may be a useful strategy to encourage the patient that this is a common experience of trauma survivors, but the immediate priority is determining patient safety.)

At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation? A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the clients case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist

B. (To meet Joint Commission standards, an in-person evaluation by a physician or LIP should be conducted within 1 hour of the initiation of restraints.)

A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. Administering psychotropic medications can be a part of violence-intervention protocols. B. Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols. C. Applying leather restraints can be a part of violence-intervention protocols. D. Calling for assistance is a part of violence-intervention protocols.

B. (Touching the client could be seen by him or her as threatening and provoke further violence.)

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? Select all that apply. A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy

B.C. (The nurse should explain to the client that systematic desensitization and imploding are the most commonly used behavioral therapies in the treatment of phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.)

A mother brings her son to the Emergency Department and tells the nurse that her son must have PTSD, because 2 days ago he witnessed a car accident in which there were fatalities. She is convinced that her son has PTSD because he has been crying when he talks about the incident. She believes that boys are at greater risk for PTSD because they dont typically cry. She read on the internet that PTSD can have dangerous consequences, so she wants her son to get some medication to cure the PTSD before it gets too bad. Which of these statements by the nurse would accurately correct this mothers misunderstanding about PTSD? Select all that apply. A. There are no long-term or dangerous consequences from PTSD. B. Women appear to be at greater risk of this disorder than men. C. Medications have been found to be effective in treating symptoms of depression or anxiety but do not represent a cure for the disorder. D. Fewer than 10% of trauma victims develop PTSD.

B.C.D. (Items B, C, and D are evidence-based pieces of information. Item A is incorrect since, in fact, dangerous consequences of unmanaged PTSD may include depression and/or suicide.)

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

B.C.D. (The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the clients symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).)

Samuel, a 19-year-old high school student, has been admitted to the psychiatric unit with a diagnosis of adjustment disorder with disturbance of conduct. He assaulted a teacher when he was told he was receiving detentions for a pattern of tardiness. The nurse, while completing rounds, finds the patient in his room crying, and one of his wrists is bleeding from a self-inflicted cut made by a piece of metal from an unknown source. Prioritize each of the following nursing interventions from 1 to 5, with 1 being the highest priority. ___ A. Check the patients vital signs. ___ B. Assess the wound site. ___ C. Contact the parents. ___ D. Discuss with Samuel what precipitated this event. ___ E. Cleanse and treat the wound site to prevent infection.

B.E.A.D.C.

A 2-year-old engages in frequent temper tantrums that usually result in the parents giving in to demands. During family therapy, how should a nurse counsel the parents? A. You are shaping your childs behavior. B. Your child has modeled your behavior. C. You are positively reinforcing your childs behavior. D. You are negatively reinforcing your childs behavior.

C.

A client is in the late stage of Alzheimers disease. To address the clients symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.

C.

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.

C. (A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be at risk for suicide.)

Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

C. (A degree of the responsibility for the suicidal clients safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.)

A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide? A. Family history of depression B. The clients orientation to reality C. The clients history of suicide attempts D. Family support systems

C. (A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the clients risk.)

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

C. (A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimers disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.)

A nurse understands that the abnormal secretion of growth hormone may play a role in which illness? A. Acute mania B. Schizophrenia C. Anorexia nervosa D. Alzheimers disease

C. (A nurse should understand that research has found a correlation between abnormal levels of growth hormone and anorexia nervosa. The growth hormone is responsible for growth in children, as well as continued protein synthesis throughout life.)

Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security

C. (A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior.)

A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

C. (A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.)

A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

C. (Altered thinking can affect a clients insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.)

The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics: A. Remain in the system longer B. Act more quickly to reduce delusions C. Produce fewer extrapyramidal effects D. Are risk free for neuroleptic malignant syndrome (NMS)

C. (Atypical antipsychotics produce less D2blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quicklyto reduce delusions. The atypicals are not risk free for NMS.)

A nurse on an inpatient unit helps a client understand the significance of treatments and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the Tidal Model of Recovery? A. Know that Change Is Constant B. Reveal Personal Wisdom C. Be Transparent D. Give the Gift of Time

C. (Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Be Transparent commitment.)

A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours ago. The patient will need teaching about a drug from which group? A. Tricyclic antidepressants B. Antimanic drugs C. Benzodiazepines D. Antipsychotic drugs

C. (Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Antimanic drugs are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis.)

Which client statement reflects an understanding of the effect of circadian rhythms on a persons ability to function? A. When I dream about my mothers horrible train accident, I become hysterical. B. I get really irritable during my menstrual cycle. C. Im a morning person. I get my best work done in the a.m. D. Every February, I tend to experience periods of sadness.

C. (By stating, I am a morning person, the client demonstrates an understanding that circadian rhythms may influence a variety of regulatory functions, including the sleepwake cycle, regulation of body temperature, and patterns of activity. Most humans follow a 24-hour cycle that is largely affected by light and darkness.)

How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

C. (Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.)

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

C. (Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.)

A mother tells her teenager that in order for college tuition to be paid, the teenager must quit smoking. They develop a written agreement stipulating time frames and consequences. This is an example of which technique of behavior modification? A. Shaping B. Modeling C. Contracting D. Premack principle

C. (Contracting occurs when the mother and teenager together develop a written agreement related to desired behavior (smoking cessation) and positive reinforcement (paid college tuition).)

A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurses initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.

C. (During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurses initial action should focus on removing the client from the stimulating environment to a calmer location.)

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this clients symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

C. (Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this clients fainting to the loss of alkaline stool due to laxative abuse, which would lead to a relative metabolic acidotic condition.)

During hospitalization, an attention-seeking client has repeatedly cut herself. After threatening to cut herself again, the nurse states, Here are some Band-Aids so you wont bleed on the sheets. Which is the underlying reason for this nurses response? A. The nurse is using an aversive stimulus in response to the clients manipulative cutting behavior. B. The nurse is using negative reinforcement in response to the clients behavior. C. The nurse is minimizing reinforcement of the clients manipulative behavior with the goal of extinction. D. The nurse lacks empathy for the clients recurring self-injurious behavior.

C. (Extinction is the gradual decrease in frequency or disappearance of a response when a positive reinforcement is withheld. The nurse is withholding attention to the client who is exhibiting manipulative, attention-seeking behavior. The lack of positive response (attention) should cause extinction of the undesired behavior)

A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms? A. Decreased dopamine at receptor sites B. Blockade of histamine C. Cholinergic blockade D. Adrenergic blocking

C. (Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation.)

The client states, I get into trouble because I respond violently without thinking. That usually gets me into a mess. Which nursing reply would be most therapeutic to address this clients problem? A. Everybody loses their temper. Its good that you know that about yourself. B. Ill bet you have some interesting stories to share about overreacting. C. Lets explore methods to help you stop and think before taking action. D. Its good that you are showing readiness for behavioral change.

C. (Helping the client to find alternative ways to release tension by more appropriate problem-solving behaviors is a therapeutic nursing intervention.)

Studies have suggested that re-experiencing a traumatic event can become an addiction of sorts. The evidence suggests that the reason for this is: A. People with PTSD often have addictive personalities. B. Perpetuating the traumatic experience yields secondary gains. C. The re-experiencing of trauma enhances production of endogenous opioid peptides. D. People with PTSD often have concurrent substance abuse issues.

C. (Hollander and Simeon (2008) report on studies suggesting that the release of endogenous opioid peptides can produce an addiction to the trauma. There is no evidence suggesting that addictive personality traits are responsible for chronicity in PTSD symptoms. Items B and D are possible outcomes in any individual with PTSD, but neither has been correlated to an addiction to re-experiencing trauma.)

The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a: A. 30 mm Hg decrease in blood pressure reading B. Respiratory rate of 24 respirations per minute C. Temperature reading of 104° F D. Pulse rate of 70 beats per minute

C. (Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate.)

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

C. (Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia)

A client states, I hear voices that tell me that I am evil. Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the clients personality structure.

C. (It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.)

Sandy, a rape survivor, is being treated for PTSD. Which of these statements are good indications that Sally is beginning to recover from PTSD? A. I still have nightmares every night, but I dont always remember them anymore. B. Im not drinking as much alcohol as I had been over the last several months. C. This traumatic event immobilized me for awhile, but I have found imagery helpful in reducing my anxiety. D. All of the above.

C. (Item C demonstrates evidence of awareness of the impact the trauma had on Sandys life and demonstrates evidence of effective coping skills. Item A indicates continued presence of symptoms and possibly amnesia. Although item B may be evidence of a positive coping strategy, evaluation of recovery from PTSD must also include assessment for less symptoms such as nightmares and flashbacks.)

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this clients symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

C. (Learning theory describes a model of learned helplessness in which multiple life failures cause the client to abandon future attempts to succeed.)

A patient tells a nurse, "My doctor prescribed Paxil [paroxetine] for my depression. I suppose I'll have side effects like I had when I was taking Tofranil [imipramine]." The nurse's reply should be based on the knowledge that paroxetine is a(n): A. tricyclic antidepressant B. MAOI C. selective serotonin reuptake inhibitor D. selective norepinephrine reuptake inhibitor

C. (Paroxetine is a selective serotonin reuptake inhibitor and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.)

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns Risk for other-directed violence as the clients priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift.

C. (Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer A does not contain a time frame.)

Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out? A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Reflecting back to the client empathy about the clients distress D. Presenting appropriate values that need to be modified

C. (Reflecting back to the client empathy about the clients distress promotes a trusting relationship and may prevent the clients anxiety from escalating when limits are set.)

Warrens college roommate actively resists going out with friends whenever they invite him. He says he cant stand to be around other people and confides to Warren They wouldnt like me anyway. Which disorder is Warrens roommate likely suffering from? A. Agoraphobia B. Mysophobia C. Social anxiety disorder (social phobia) D. Panic disorder

C. (Social anxiety disorder is an excessive fear of social situations R/T fear that one might do something embarrassing or be evaluated negatively by others.)

A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

C. (Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression.)

A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse managers best reply? A. Suicide is a DSM-5 diagnosis. B. Suicide is a mental disorder. C. Suicide is a behavior. D. Suicide is an antisocial affliction.

C. (Suicide is not a diagnosis, disorder, or affliction. It is a behavior.)

A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha-1 receptors because the patient may experience: A. increased psychotic symptoms. B. a hypertensive crisis. C. orthostatic hypotension. D. severe appetite disturbance.

C. (Sympathetic mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of alpha-1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Patients should be taught ways of minimizing this phenomenon.)

A client reports, My friend panicked at the site of spiders. Her therapist used gradual exposure to spiders that initially made her increasingly more anxious. Which technique was the friends therapist most likely using? A. Extinction B. Covert sensitization C. Systematic desensitization D. Reciprocal inhibition

C. (Systematic desensitization is a treatment for phobias in which a phobic individual is gradually exposed to increasing amounts of the phobic stimulus while practicing relaxation techniques. Eventually, the phobic stimulus causes little or no anxiety.)

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

C. (The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three yes answers strongly suggests a problem with alcohol.)

A clients wife has been making excuses for her alcoholic husbands work absences. In family therapy, she states, I just need to work harder to get him there on time. Which is the appropriate nursing response? A. Why do you assume responsibility for his behaviors? B. Codependency is a typical behavior of spouses of alcoholics. C. Your husband needs to deal with the consequences of his drinking. D. Do you understand what the term enabler means?

C. (The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited.)

A drug causes muscarinic receptor blockade. A nurse will assess the patient for: A. gynecomastia B. pseudoparkinsonism C. orthostatic hypotension D. dry mouth

D. (Muscarinic receptor blockade includes atropine-like side effects such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with alpha-1 antagonism.)

A client diagnosed with alcohol use disorder joins a community 12-step program and states, My life is unmanageable. How should the nurse interpret this clients statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

C. (The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.)

A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the clients behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

C. (The initial nursing action is to assess environmental triggers and potential unmet needs. Due to the cognitive decline experienced in a client diagnosed with neurocognitive disorder, communication skills may be limited. The client may become disoriented and frustrated.)

How should a nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care because of physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.

C. (The major maladaptive client response to panic disorder is the perception of having no control over life situations, which leads to nonparticipation in decision making and doubts regarding role performance.)

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the clients paranoid perceptions.

C. (The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.)

A client diagnosed with schizophrenia states, Cant you hear him? Its the devil. Hes telling me Im going to hell. Which is the most appropriate nursing reply? A. Did you take your medicine this morning? B. You are not going to hell. You are a good person. C. Im sure the voices sound scary. I dont hear any voices speaking. D. The devil only talks to people who are receptive to his influence.

C. (The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.)

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. Tell him to stop discussing the voices. B. Ignore what he is saying, while attempting to discover the underlying cause. C. Focus on the feelings generated by the hallucinations and present reality. D. Present objective evidence that the voices are not real.

C. (The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.)

A client diagnosed with antisocial personality disorder comes to a nurses station at 11:00 p.m., requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. Go ahead and use the phone. I know this pending divorce is stressful. B. You know better than to break the rules. Im surprised at you. C. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow. D. The decision to divorce should not be considered until you have had a good nights sleep.

C. (The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.)

An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, the nurse would most appropriately make which statement? A. Make sure you concentrate on taking slow, deep, cleansing breaths. B. Watch your diet and try to engage in some regular physical activity. C. Rise slowly when you change position from lying to sitting or sitting to standing. D. Wear sunscreen and try to avoid midday sun exposure.

C. (The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.)

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? A. The client will communicate all needs verbally by discharge. B. The client will participate with peers in a team sport by day 4. C. The client will establish trust with at least one caregiver by day 5. D. The client will perform most self-care tasks independently.

C. (The most realistic client outcome for a child diagnosed with autism spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction)

A client is experiencing a severe panic attack. Which nursing intervention would meet this clients immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)

C. (The nurse can meet this clients immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life, and the presence of a trusted individual provides assurance of personal safety.)

Upon admission for symptoms of alcohol withdrawal, a client states, I havent eaten in 3 days. Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

C. (The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.)

Which client diagnosis should a nurse associate with a decrease in gamma-aminobutyric acid (GABA)? A. Alzheimers disease B. Schizophrenia C. Panic disorder D. Depression

C. (The nurse should associate a decrease in GABA with panic disorder. Enhancement of the GABA system is the mechanism of action by which benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the GABA system are also associated with movement disorders and epilepsy.)

A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder

C. (The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.)

A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurses priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.

C. (The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self- destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.)

At what time during a 24-hour period should a nurse expect clients with Alzheimers disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications

C. (The nurse should determine that clients with Alzheimers disease exhibit more pronounced symptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the late afternoon and evening)

A client diagnosed with schizophrenia states, My psychiatrist is out to get me. Im sad that the voice is telling me to stop him. What symptom is the client exhibiting, and what is the nurses legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

C. (The nurse should determine that the client is exhibiting command hallucinations. The nurses legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.)

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

C. (The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).)

A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge. B. Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response. C. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety. D. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.

C. (The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety-provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.)

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply? A. Thats strange. Weight loss is the typical pattern. B. What have you been eating? Weight gain is not usually associated with lithium. C. Weight gain is a common but troubling side effect. D. Weight gain occurs only during the first month of treatment with this drug.

C. (The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication)

A client diagnosed with generalized anxiety states, I know the best thing for me to do now is to just forget my worries. How should the nurse evaluate this statement? A. The client is developing insight. B. The clients coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.

C. (This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.)

A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her childs attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mothers concern? A. The physician will probably switch from Ritalin to a central nervous system stimulant. B. The physician may prescribe an antihistamine with the Ritalin to improve effectiveness. C. Your child has probably developed a tolerance to Ritalin and may need a higher dosage. D. Your child has developed sensitivity to Ritalin and may be exhibiting an allergy.

C. (The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate (Ritalin) is a central nervous system stimulant in which tolerance can develop rapidly. Physical and psychological dependence can also occur.)

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment

C. (The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.)

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)

C. (The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.)

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)? A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity

C. (The nurse should identify that attention and concentration are impaired in neurocognitive disorder and not in pseudodementia (depression).)

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the clients motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

C. (The nurse should identify that behavior modification therapy will be used because it provides the client with control over behavioral choices. Clients diagnosed with anorexia nervosa are often allowed to contract privileges based on weight gain. The client maintains control over eating and exercise.)

A clients altered body image is evidenced by claims of feeling fat, even though the client is emaciated. Which is the appropriate outcome criterion for this clients problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

C. (The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self on the basis of self-attributes instead of appearance and to realize that perfection is unrealistic.)

Which part of the nervous system should a nurse identify as playing a major role during stressful situations? A. Peripheral nervous system B. Somatic nervous system C. Sympathetic nervous system D. Parasympathetic nervous system

C. (The nurse should identify that the sympathetic nervous system plays a major role during stressful situations. The sympathetic nervous system prepares the body for the fight-or-flight response. The parasympathetic nervous system is dominant when an individual is in a nonstressful state.)

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

C. (The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behaviors.)

Looking at a slightly bleeding paper cut, the client screams, Somebody help me, quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

C. (The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over-gregarious, and seductive.)

During group therapy, a client diagnosed with alcohol use disorder states, I would not have boozed it up if my wife hadnt been nagging me all the time to get a job. She never did think that I was good enough for her. How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

C. (The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.)

After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimers disease. What should cause the nurse to question this diagnosis? A. Neurocognitive disorder does not typically occur in African American clients. B. The symptoms presented are more indicative of Parkinsonism. C. Neurocognitive disorder does not develop suddenly. D. There has been no T3 or T4 level evaluation ordered.

C. (The nurse should know that neurocognitive disorder (NCD) does not develop suddenly and should question this diagnosis. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed. The disease is generally progressive and debilitating.)

A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this clients risk for suicide? A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times

C. (The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.)

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3

C. (The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients physical and safety needs.)

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

C. (The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.)

A client diagnosed with brief psychotic disorder tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

C. (The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.)

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior? A. Dendrites B. Axons C. Neurotransmitters D. Synapses

C. (The nurse should recognize that neurotransmitters play an essential function in the role of human emotion and behavior. Neurotransmitters are targeted and affected by many psychotropic medications.)

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition? A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism

C. (The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). In NCD, impairment is evident in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate.)

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed.

C. (The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious and formal and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.)

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

C. (The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.)

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self- harm. The client refuses to commit to developing a plan for safety. What should be the nurses priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide

C. (The nurses priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.)

Which of these statements by the patient are indications of complicated grieving? A. I feel like I should have been the one to die in that hurricane. B. Last year, several of my coworkers died in a hurricane and I still cant go back to work. C. Ive been having incapacitating migraines ever since the memorial services. D. All of the above

D. (Item A indicates survivor guilt, and items B and C are both indications that the trauma has contributed to functional impairment. All three are symptoms of complicated grieving.)

When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites

C. (The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.)

A nurse discovers a clients suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the clients threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the clients threat must be addressed

C. (The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.)

A college student is unable to take a final examination because of severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

C. (The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the clients healthy coping skills and reduce anxiety.)

A client diagnosed with neurocognitive disorder due to Alzheimers disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis? A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance

C. (The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury.)

On the first day of a clients alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

C. (The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.)

Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. B. Convey unconditional acceptance and positive regard. C. Recognize escalating aggressive behaviors and intervene before violence occurs. D. Provide immediate positive feedback for appropriate behaviors.

C. (The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behaviors and to intervene before violence occurs. This intervention serves to keep the client and others safe. This is the priority nursing concern.)

An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order? A. This dosage is within the recommended dosage range. B. This dosage is lower than the recommended dosage range. C. This dosage is more than twice the recommended dosage range. D. This dosage is four times higher than the recommended dosage range.

C. (The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily.)

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

C. (The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.)

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

C. (The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, and measurable and also include a time frame.)

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The clients understanding of the need for regular bloodwork B. The clients mood and affect score, according to the facilitys mood scale C. The clients cognitive ability to understand information about the medication D. The clients access to a support network willing to participate in treatment

C. (There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.)

A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

C. (Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.)

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100-mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 mL

C. (Twenty mg of Prozac multiplied by three results in the calculated 60-mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.)

A client is in therapy with a nurse practitioner for the treatment of arachnophobia. The nurse practitioner decides to use the technique of flooding. Which intervention best exemplifies this technique? A. Giving rewards for demonstrating a decrease in fear of spiders B. Encouraging the client to sit through the movie Spiderman C. Accompanying the client to a 1-hour visit to the local zoos spider room D. Offering a computer program that progressively presents anxiety-producing spider scenarios

C. (Visiting the spider room would flood the client with the phobic stimuli of real spiders. This would continue until the stimulus no longer creates anxiety.)

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the clients attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

C. (When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.)

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time? A. To shift the clients focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

C. (When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.)

The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

D. (Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.)

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

D. (A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life- threatening symptoms that occur because of the rebound reaction of the central nervous system.)

Which client statement demonstrates positive progress toward recovery from a substance use disorder? A. I have completed detox and therefore am in control of my drug use. B. I will faithfully attend Narcotic Anonymous (NA) when I cant control my cravings. C. As a church deacon, my focus will now be on spiritual renewal. D. Taking those pills got out of control. It cost me my job, marriage, and children.

D. (A client who takes responsibility for the consequences of substance use is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process, in which he or she accepts the fact that substance use causes problems.)

Parents decide to try the nurse practitioners suggestion of time out when their child misbehaves. What teaching should the nurse practitioner provide the parents? A. Correct your childs behavior by spanking for a specified time period. B. Ignore the childs negative behavior. C. Add positive reinforcement for acceptable behavior. D. Temporarily move your child to an area where behavior is not being reinforced.

D. (A time out is an aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is occurring. Usually during a time out, the person is temporarily isolated so there is no reinforcing attention. This discourages a reoccurrence of the undesired behavior.)

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents

D. (An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression.)

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

D. (An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.)

A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement

D. (Anger can lead to aggression when the coping response is displacement. This client has discharged anger against a person (the nurse) unrelated to the true target of the anger (the spouse).

25. Which client statement would demonstrate a common characteristic of Cluster B personality disorder? A. I wish someone would make that decision for me. B. I built this building by using materials from outer space. C. Im afraid to go to group because it is crowded with people. D. I didnt have the money for the ring, so I just took it.

D. (Antisocial personality disorder is included in the Cluster B personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.)

A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

D. (Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions.)

A patient has taken many conventional antipsychotic drugs over years. The health care provider, concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: A. are less costly. B. have higher potency. C. are more readily available. D. produce fewer motor side effects.

D. (Atypical antipsychotic drugs often exert their action on the limbic system rather than the basal ganglia. The limbic system is not involved in motor disturbances. Atypical antipsychotics are not more readily available. They are not considered to be of higher potency; rather, they have different modes of action. Atypical antipsychotic drugs tend to be more expensive.)

When asked to identify principles that define the term maladaptive behavior, which nursing student statement indicates that further teaching is needed? A. Behavior is maladaptive when it is age inappropriate. B. Behavior is maladaptive when it interferes with adaptive functioning. C. Behavior is maladaptive when it is identified as inappropriate in the context of ones culture. D. Behavior is maladaptive when it results in change within an otherwise stable subsystem.

D. (Behaviors that result in change within a subsystem, even when it is stable, could be either adaptive or maladaptive behaviors. This statement, therefore, is incorrect.)

The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom dcor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? A. Rooms should contain extra-large windows with views of the street. B. Rooms should contain brightly colored walls with printed drapes. C. Rooms should be painted deep colors and located close to the nurses station. D. Rooms should be painted with neutral colors and contain pale-colored accessories.

D. (Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the clients environment (low lighting, few people, simple dcor, low noise levels). Anxiety levels rise in a stimulating environment. Neutral colors and pale accessories are most appropriate for a client experiencing mania.)

After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the clients return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing

D. (Debriefing is an important part of restraint/seclusion. It allows the staff an opportunity to review and learn from the experience and to express feelings generated by the incident.)

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

D. (Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.)

A patient is hospitalized for severe depression. Of the medications listed below, a nurse can expect to provide the patient with teaching about: A. clozapine (Clozaril) B. chlordiazepoxide (Librium) C. tacrine (Cognex) D. fluoxetine (Prozac)

D. (Fluoxetine is an SSRI. It is an antidepressant that blocks the reuptake of serotonin with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine is used to treat Alzheimer's disease.)

A nurse can anticipate anticholinergic side effects are likely when a patient is taking: A. lithium (Lithobid). B. isperidone (Risperdal). C. buspirone (BuSpar). D. fluphenazine (Prolixin)

D. (Fluphenazine, a first-generation antipsychotic, exerts muscarinic blockade, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.)

A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the clients safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.

D. (Forgetfulness is an early symptom of dementia that would alert the nurse to question the clients safety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease. The cause of vascular dementia is related to an interruption of blood flow to the brain. High blood pressure and hypertension are significant factors in the etiology.)

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. Its just a matter of time and I will be well. B. If I ignore these feelings, they will go away. C. I can fight these feelings and overcome this disorder. D. Nothing will help me feel better.

D. (Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.)

A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

D. (Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.)

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. Only oral ingestion of alcohol will cause a reaction when taking this drug. B. It is safe to drink beverages that have only 12% alcohol content. C. This medication will decrease your cravings for alcohol. D. Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug.

D. (If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks)

On the basis of current knowledge of neurotransmitter effects, a nurse could anticipate that the treatment plan for a patient with memory difficulties might include medications designed to: A. inhibit GABA. B. increase dopamine at receptor sites. C. decrease dopamine at receptor sites. D. prevent destruction of acetylcholine.

D. (Increased acetylcholine plays a role in learning and memory. Preventing destruction of acetylcholine by acetylcholinesterase would result in higher levels of acetylcholine, with the potential for improved memory. GABA is known to affect anxiety level rather than memory. Increased dopamine would cause symptoms associated with schizophrenia or mania rather than improve memory. Decreasing dopamine at receptor sites is associated with Parkinson's disease rather than improving memory.)

A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? A. Suicidal threats and gestures should be considered manipulative and/or attention-seeking. B. Suicide is the act of a psychotic person. C. All suicidal individuals are mentally ill. D. Fifty to eighty percent of all people who kill themselves have a history of a previous attempt.

D. (It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt. All other answer choices are myths about suicide.)

A kindergarten rule states that if unacceptable behavior occurs, a childs personalized fish will be moved to the sea grass. Children who behave keep their fish out of the sea grass. The school nurse should identify this intervention as based on which principle of behavior therapy? A. Classical conditioning B. Conditioned response C. Positive reinforcement D. Negative reinforcement

D. (Negative reinforcement is increasing the probability that behavior (appropriate classroom behavior) will recur by removal of an undesirable reinforcing stimulus (personalized fish in sea grass).)

A nurse assesses that a patient demonstrates anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? A. GABA B. Histamine C. Acetylcholine D. Norepinephrine

D. (Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight." GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.)

The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the teams decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

D. (Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety.)

A student nurse is studying the effect of the drug isocarboxazid (Marplan) on neurobiology. The student should recognize that the neurotransmitter serotonin is catabolized by which enzyme? A. Glycosyltransferase B. Peptidase C. Polymerase D. Monoamine oxidase

D. (Serotonin that is not returned to be stored in the axon terminal vesicles is catabolized by the enzyme monoamine oxidase. A monoamine oxidase inhibitor, such as Marplan, inhibits this catabolism, providing more available serotonin at the neuron synapse.)

Which assumption is most reflective of a behavioral theory model? A. Mental illness is characterized by structural and biochemical alterations. B. Thought processes influence behaviors. C. All personality development has a social context. D. There is a basic relationship between stimulus and response.

D. (That there is a basic relationship between stimulus and response is an assumption of a behavioral theory model. The connection between a stimulus and a response is strengthened or weakened by the consequences of the response.)

After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours

D. (The Joint Commission (JCAHO) requires that a physician or licensed independent provider (LIP) must reissue a new order for restraints every 4 hours for adults, every 1 hour for clients younger than 9, and every 2 hours for clients 9 to 17 years.)

A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step? A. Step 3: Triggers that cause distress or discomfort are listed. B. Step 4: Signs indicating relapse are identified and plans for responding are developed. C. Step 5: A specific plan to help with symptoms is formulated. D. Step 6: Following client-designed plan, caregivers now become decision-makers.

D. (The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include Step 1, Develop a Wellness Toolbox; Step 2, Daily Maintenance List; Step 3, Triggers; Step 4, Early Warning Signs; Step 5, Things Are Breaking Down or Getting Worse; and Step 6, Crisis Planning. In Step 6 (Crisis Planning), clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed. All other actions presented require the client to be functionally capable.)

Which situation presents an example of the basic concept of a recovery model? A. The clients family is encouraged to make decisions in order to facilitate discharge. B. A social worker, discovering the clients income, changes the clients discharge placement. C. A psychiatrist prescribes an antipsychotic drug on the basis of observed symptoms. D. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.

D. (The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care.)

Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay. B. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you dont stay with me. C. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please dont go! I cant sleep without you being here. D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me.

D. (The clients statement I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.)

During a one-to-one session with a client, the client states, Nothing will ever get better, and Nobody can help me. Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements

D. (The clients statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the clients suicidal ideations and intent would be necessary.)

A patient has disorganized thinking associated with schizophrenia. A PET scan would most likely show dysfunction in which part of the brain? A. Temporal lobe B. Cerebellum C. Brainstem D. Frontal lobe

D. (The frontal lobe is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.)

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the clients boundaries.

D. (The most appropriate nursing intervention is to provide personal space to respect the clients boundaries. Providing personal space may serve to reduce anxiety and thus reduce the clients risk for violence.)

A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client, Do you receive special messages from certain sources, such as the television or radio? Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference

D. (The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.)

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurses rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

D. (The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.)

A client diagnosed with major depressive disorder states, Ive been feeling down for 3 months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients affective symptoms? A. Have you been diagnosed with any physical disorder within the last 3 months? B. Have you ever felt this way before? C. People who have mood changes often feel better when spring comes. D. Help me understand what you mean when you say, feeling down?

D. (The nurse is using a clarifying statement in order to gather more details related to this clients mood.)

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

D. (The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.)

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

D. (The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.)

During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. I really dont have a problem. My family is inflexible, and every relative is out to get me. B. I am so excited about working with you. Have you noticed my new nail polish, Ruby Red Roses? C. I spend all my time tending my bees. I know a whole lot of information about bees. D. I am getting a message from the beyond that we have been involved with each other in a previous life.

D. (The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.)

A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse should associate this response with which neurotransmitter? A. Acetylcholine B. Dopamine C. Serotonin D. Norepinephrine

D. (The nurse should associate the neurotransmitter norepinephrine with the fight-or-flight response. Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is associated with the regulation of mood, cognition, perception, locomotion, sleep, and arousal.)

A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

D. (The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.)

A client is admitted to an emergency department experiencing memory deficits and decreased motor function. What alteration in brain chemistry should a nurse correlate with the presentation of these symptoms? A. Abnormal levels of serotonin B. Decreased levels of dopamine C. Increased levels of norepinephrine D. Decreased levels of acetylcholine

D. (The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine. Acetylcholine is a major effector chemical of the autonomic nervous system. Functions of acetylcholine include sleep regulation, pain perception, the modulation and coordination of movement, and memory.)

Which client statement indicates a knowledge deficit related to substance use? A. Although its legal, alcohol is one of the most widely abused drugs in our society. B. Tolerance to heroin develops quickly. C. Flashbacks from LSD use may reoccur spontaneously. D. Marijuana is like smoking cigarettes. Everyone does it. Its essentially harmless.

D. (The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have potentially harmful effects. Cannabis is the second most widely abused drug in the United States.)

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this clients problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

D. (The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the clients room are not appropriate interventions because they do not help the client recognize anxiety triggers.)

A highly agitated client paces the unit and states, I could buy and sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior? A. Rates mood 8/10. Exhibiting looseness of association. Euphoric. B. Mood euthymic. Exhibiting magical thinking. Restless. C. Mood labile. Exhibiting delusions of reference. Hyperactive. D. Agitated and pacing. Exhibiting grandiosity. Mood labile.

D. (The nurse should document that this clients behavior is Agitated and pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.)

A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin) D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

D. (The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.)

An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft)

D. (The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the clients social functioning and concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder.)

A client diagnosed with major depressive disorder asks, What part of my brain controls my emotions? Which nursing response is appropriate? A. The occipital lobe governs perceptions, judging them as positive or negative. B. The parietal lobe has been linked to depression. C. The medulla regulates key biological and psychological activities. D. The limbic system is largely responsible for ones emotional state.

D. (The nurse should explain to the client that the limbic system is largely responsible for ones emotional state. This system is often called the emotional brain and is associated with feelings, sexuality, and social behavior. The occipital lobes are the area of visual reception and interpretation. Somatosensory input (touch, taste, temperature, etc.) occurs in the parietal lobes. The medulla contains vital centers that regulate heart rate and reflexes.)

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions the Zyprexa order. Which is the appropriate nursing reply? A. Zyprexa in combination with Eskalith cures manic symptoms. B. Zyprexa prevents extrapyramidal side effects. C. Zyprexa ensures a good nights sleep. D. Zyprexa calms hyperactivity until the Eskalith takes effect.

D. (The nurse should explain to the clients spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes.)

A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? A. You really dont have to go by that schedule. Id just stay home sick. B. There has got to be a hidden agenda behind this schedule change. C. Who do you think you are? I expect to interact with the same nurse every Saturday. D. You cant make these kinds of changes! Isnt there a rule that governs this decision?

D. (The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.)

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization

D. (The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.)

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

D. (The nurse should interpret that the clients symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage.)

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

D. (The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.)

How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.

D. (The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.)

A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness? A. Mania B. Schizophrenia C. Anxiety D. Depression

D. (The nurse should recognize that a decrease in norepinephrine levels would play a significant role in generating the symptoms of depression. The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.)

A client diagnosed with neurocognitive disorder due to Alzheimers disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

D. (The nurse should recognize that this client is in the late stage of Alzheimers disease. The late stage is characterized by a severe cognitive decline.)

A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of panic anxiety

D. (The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be panic anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.)

A confused client has recently been prescribed sertraline (Zoloft). The clients spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

D. (The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.)

During the planning of care for a suicidal client, which correctly written outcome should be a nurses first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay.

D. (The nurses priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurses priority. The A answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, and realistic and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated)

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. Treatment is compromised when clients cant sleep. B. Treatment is compromised when irritability interferes with social interactions. C. Treatment is compromised when clients have no insight into their problems. D. Treatment is compromised when clients choose not to take their medications.

D. (The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications. Symptoms of bipolar disorder will reemerge if medication is stopped.)

A client diagnosed with neurocognitive disorder due to Alzheimers disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the clients room with name and number D. Assist with bathing and toileting

D. (The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.)

A clients wife of 34 years dies unexpectedly. The client cries often and becomes socially isolated. The clients therapist stresses the importance of proper sleep, nutrition, and exercise. What is the best rationale for the therapists advice? A. The therapist is using an interpersonal approach. B. The client has an alteration in neurotransmitters. C. It is routine practice to remind clients about nutrition, exercise, and rest. D. The client is susceptible to illness due to effects of stress on the immune system.

D. (The therapists advice should be based on the knowledge that the client has been exposed to stressful stimuli and is at an increased risk of developing illness due to the effects of stress on the immune system. The study of this branch of medicine is called psychoimmunology.)

During a smoking cessation group, the community health nurse explains that in their effort to quit smoking, a reciprocal inhibition approach will be used. The nurse should give the group which example of this technique? A. Before you can smoke, you must first take a half-hour walk. B. When you have the urge to smoke, imagine being short of breath. C. Youll receive $1 for each cigarette not smoked and forfeit $2 for each cigarette smoked. D. When you have the urge to smoke, hold your breath and then rhythmically breathe.

D. (These breathing exercises cannot be done while the client smokes. Therefore, they decrease or eliminate the undesired behavior (smoking) that is incompatible with the desired behavior (smoking cessation). This is an example of the behavior therapy of reciprocal inhibition.)

A child always chooses to ask mother over father when seeking special privileges. The father is more apt to disagree than agree with the childs requests, whereas the mother usually consents. The childs choice is the result of which component of operant conditioning? A. Conditioned stimuli B. Unconditioned stimuli C. Aversive stimuli D. Discriminative stimuli

D. (This child is able to discriminate between stimuli. This child can predict with assurance that asking mother (not father) will result in a desired response.)

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects a theory about the underlying etiology of this disorder? A. I was just trying to be like everyone else. B. All the skaters on the team are following an approved 1,200-calorie diet. C. When I lose skating competitions, I also lose my appetite. D. I am angry at my mother. I can get her approval only when I win competitions.

D. (This client statement reflects a possible underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family members development of anorexia nervosa.)

A suicidal client says to a nurse, Theres nothing to live for anymore. Which is the most appropriate nursing reply? A. Why dont you consider doing volunteer work in a homeless shelter? B. Lets discuss the negative aspects of your life. C. Things will look better in the morning. D. It sounds like you are feeling pretty hopeless.

D. (This statement verbalizes the clients implied feelings and allows him or her to validate and explore them.)

A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client.

D. (To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space.)

A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

D. (To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.)

The nurse plans to confront a client about secondary gains related to extreme dependency on her spouse. Which nursing statement would be most appropriate? A. Do you believe dependency issues have been a lifelong concern for you? B. Have you noticed any anxiety during times when your husband makes decisions? C. What do you know about individuals who depend on others for direction? D. How have the specifics of your relationship with your spouse benefited you?

D. (When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that they might not otherwise receive.)

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. I do not use any laxatives or diuretics to lose weight. B. I am losing lots of hair. Its coming out in handfuls. C. I know that I am thin, but I refuse to be fat! D. I dont know why people are worried. I need to lose this weight.

D. (When the client states, I dont know why people are worried. I need to lose this weight, the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.)

16. Order the six steps of The Wellness Recovery Action Plan (WRAP) Model as described by Copeland et al. A.________ Daily Maintenance List B.________ Things Are Breaking Down or Getting Worse C. ________Crisis Planning D.________ Develop a Wellness Toolbox E._________Early Warning Signs F. ________ Triggers

D.A.F.E.B.C.

Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply. A. Apathy B. Social withdrawal C. Anhedonia D. Galactorrhea E. Gynecomastia

D.E. (Dopamine blockage, an expected action of antipsychotic medications, also results in prolactin elevation. Galactorrhea and gynecomastia are symptoms of prolactin elevation.)

Which types of adoption studies should a nurse recognize as providing useful information for the psychiatric community? A. Studies in which children with mentally ill biological parents are raised by adoptive parents who were mentally healthy B. Studies in which children with mentally healthy biological parents are raised by adoptive parents who were mentally ill C. Studies in which monozygotic twins from mentally ill parents were raised separately by different adoptive parents D. Studies in which monozygotic twins were raised together by mentally ill biological parents E. All of the above

E. (The nurse should determine that all of the studies could possibly benefit the psychiatric community. The studies may reveal research findings relating genetic links to mental illness. Adoption studies allow comparisons to be made of the influences of the environment versus genetics.)