Psych Exam 2

4 cardinal features of delirium.

-Acute onset and fluctuating course. -Reduced ability to direct, focus, shift, sustain attention. -Disorganized thinking. -Disturbance of consciousness Early recognition is key.

Delirium

-Alteration in level of consciousness -Disorientation - may appear drunk -Anxiety -Agitation -Poor memory -Delusional thinking -Hallucinations -Delirium is a medical emergency

A client is brought to the hospital by her daughter, who visited this morning and found her mother to be confused and disoriented. When the client is admitted, the daughter states, "I'll take her glasses and hearing aid home, so they don't get lost." The best reply for the nurse would be: "That will be fine. I'll have you sign our hospital release form." "Because we do not have a copy of durable power of attorney, we cannot release them to you." "Don't worry. You can leave them at her bedside. We are insured for losses of this sort." "I would like to have your mother wear them. It will help her to be less confused or retain more of her orientation."

"I would like to have your mother wear them. It will help her to be less confused or retain more of her orientation."

Interventions AD

-Always identify yourself and call the person by name -Maintain face-to-face eye contact -Focus on one piece of information -Talk with the person about familiar and meaningful things -Person becomes verbally aggressive, acknowledge person feelings and shift the topic to more familiar ground. -Keep person's room well lit -Provide a low stimulation -Have clocks, calendar's, and personal items (family pictures)in clear view of the person -Reinforce patients family and personal pictures -Use symbols to assist patient in locating room, bathroom, and other areas -Limit the number of choices patient has to make -Provide finger foods to maintain nutrition

Dementia definition

-Is a broad term used to describe the progressive deterioration of cognitive functioning and intellectual changes. -It is not a disease but the collection of symptoms related to an underlying disorder. -Mild impairment will not interfere with normal activities of daily living. -Effects memory, complex attention, and problem solving. Is not reversible

Nursing Diagnosis for AD

-Risk for injury -Disturbed sleep patterns -Impaired verbal communication -Impaired social interaction -Hopelessness -Situational low self-esteem -Chronic confusion -Self-care deficit (bathing/hygiene, dressing and feeding) -Functional urinary incontinence -Nursing Diagnosis for caregiver.. -Disabled family coping -Caregiver role strain -Grieving -Interrupted family processes

Nursing diagnosis for delirium

-Risk for injury as evidenced by sensory deficit or perceptual deficits. -Acute confusion related to delirium Risk for deficient fluid volume related to unwillingness to drink. -Sleep deprivation related to impaired cerebral oxygenation or disruption in consciousness. Impaired verbal communication related to cerebral hypoxia -Self-care deficit -Impaired social interactions.

Who's at risk-Deliurim

-The hospitalized elderly. (The range is highly variable due to poor recognition of disorder) -Lower education level -Sensory impaired -UTI -Postoperative patients -Those with depression -Withdraw or toxicity from drugs and alcohol -Impaired respiratory functioning.

Signs and Symptoms progression of illness of AD

-Wandering -Unsteady gait -Forgets things (live door open and stove on) -Awake and disorganized during the night (sundowning) -Unable to do ADL's -Hallucinations (see frightening things that aren't there) Illusions (mistakes everyday objects for something frightening) -Delusions (become paranoid and think that others are doing things to confuse him or her) -Does not recognize familiar people or places -Has difficulty with short and long-term memory -Difficulty with communication (cannot find words)

THREE MAIN NEUROCOGNITIVESYNDROMES

1. Delirium- acute and often reversible 2. Mild neurocognitive disorder 3. Major cognitive disorder. Mild and major cognitive disorders encompass what is referred to as dementia

Stages of AD

1. No impairment 2. Very mild cognitive decline - forgetfulness; not evident to others 3. Mild cognitive decline - decreased ability to plan; noticeable to close relatives 4. Moderate cognitive decline - personality change; obvious memory loss 5. Moderately severe decline - disorientated to time and place 6. Severe cognitive decline 7. Very severe decline - loss of all abilities, coma/stupor; death

7. Nancy is a nurse. After talking with her mother, she became concerned enough to drive over and check onher. Her mother's appearance is disheveled, words are nonsensical, smells strongly of urine, and there is a stain on her dressing gown. Nancy recognizes that her mother's condition is likely temporary due to: a. Early onset dementia b. A mild cognitive disorder c. A urinary tract infection d. Skipping breakfast

7

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

A (Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.)

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

A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse's reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.

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

A Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe.

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

A Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

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

A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

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

A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating "My legs feel weak most of the time" is more in keeping with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder. See relationship to audience response question.

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

A Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient's energy can occur when the current panic level subsides. Respecting the patient's personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.

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

A Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

A (A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.)

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease.

A (Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.)

An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

A (Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem)

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

A (Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.)

A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

A (Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.)

A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

A (Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.)

Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

A (The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium.)

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

A (The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection.)

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

A (The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.)

Based on the current research, which patient is most likely to develop dementia? An office manager in a high-stress environment A former boxer and is now a trainer A worker in a factory where asbestos is found A bartender in a dark underground club/bar

A former boxer and is now a trainer

Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

A, B, C (Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.)

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

A, B, E The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns.

A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

A, B, E (Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.)

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

A, C, D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.

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

A, C, E Shame regarding the appearance of one's home is associated with hoarding. The behavior is usually associated with chronic low self-esteem. Hoarding results in problems of home maintenance, which may precipitate injury. The self-concept may be affected, but not body image.

What is Alzheimer's Disease

AD is a type of dementia, that develops when brain cells die or no longer function. It accounts for more than 60-80% of all dementias. It is a devastating disease that affects the person that has it and their families.

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January

ANS: A The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.

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

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

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

ANS: A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. See relationship to audience response question.

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

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

A consumer at a rehabilitative psychosocial program says to the nurse, "People are not cleaning up behind themselves in the bathrooms. The building is dirty and cluttered." How should the nurse respond? a. Encourage the consumer to discuss it at a meeting with everyone.

ANS: A Consumer-run programs range from informal "clubhouses," which offer socialization and recreation, to competitive businesses, such as snack bars or janitorial services, which provide needed services and consumer employment while encouraging independence and building vocational skills. Consumers engage in problem solving under the leadership of staff. See related audience response question.

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

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

A patient diagnosed with a serious mental illness lives independently and attends a psychosocial rehabilitation program. The patient presents at the emergency department seeking hospitalization. The patient has no acute symptoms but says, "I have no money to pay my rent or refill my prescription." Select the nurse's best action. a. Involve the patient's case manager to provide crisis intervention.

ANS: A Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This patient has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering.

A person diagnosed with a serious mental illness enters a shelter for the homeless. Which intervention should be the nurse's initial priority? b. Develop a trusting relationship.

ANS: B Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date).

ANS: A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations.

ANS: A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.

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

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

ANS: A Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding.

An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training

ANS: A Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.

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

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

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

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

A nurse's neighbor says, "My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions?" Select the nurse's best response. a. "The National Alliance on Mental Illness offers a family education series that you might find helpful."

ANS: A The National Alliance on Mental Illness (NAMI) offers a family education series that assists with the stress caregivers and other family members often experience. The nurse should not give advice about injectable medication or encourage the family member to give up on the patient.

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

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

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

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

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

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

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

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

Select all that apply. An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the patient? a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training

ANS: A, B, C The patient does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with serious mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The patient presently has a home and does not require a homeless shelter.

A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? b. "Let's look at one bad thing that happened to see if another explanation exists."

ANS: B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.

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

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

Select all that apply. Which statements most clearly indicate the speaker views mental illness with stigma? a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." e. "People with mental illness are lazy. They get government disability checks instead of working."

ANS: A, B, E Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. See related audience response question.

Select all that apply. A patient diagnosed with serious mental illness was living successfully in a group home but wanted an apartment. The prospective landlord said, "People like you have trouble getting along and paying their rent." The patient and nurse meet for a problem-solving session. Which options should the nurse endorse? a. Coach the patient in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. f. Have the case manager meet with the landlord to provide education about mental illness.

ANS: A, B, F Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be the most expeditious route to housing for this patient. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlord's defensiveness and would likely be a long and expensive undertaking. Delaying the patient's efforts to become more independent is not clinically necessary according to the data noted here; the problem is the landlord's bias and response, not the patient's illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease. See related audience response question.

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

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

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

ANS: A, C, D, F Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self. See relationship to audience response question.

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

ANS: A, D, E The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected.

Select all that apply. The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? a. Maintain stable and consistent staff. e. Make it easier to access prescribers and pay for drugs.

ANS: A, E Trust in one's providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust; therefore, interventions which stabilize staffing allow patients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI patients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when the cause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education. Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make the regimen more difficult for the patient to remember.

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

ANS: B The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

Serious mental illness is characterized as: b. a major long-term mental illness marked by significant functional impairments.

ANS: B "Serious mental illness" has replaced the term "chronic mental illness." Global impairments in function are evident, particularly social. Physical impairments may be present. Serious mental illness can be treated, but remissions and exacerbations are part of the course of the illness.

A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. b. Risk for suicide

ANS: B A patient diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

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

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

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

ANS: B Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy."

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: b. careful unobtrusive observation around the clock.

ANS: B Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? b. Supporting physiological stability

ANS: B During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.

A homeless patient diagnosed with a serious mental illness became suspicious and delusional. Depot antipsychotic medication began, and housing was obtained in a local shelter. One month later, which statement by the patient indicates significant improvement? b. "I feel comfortable here. Nobody bothers me."

ANS: B Evaluation of a patient's progress is made based on patient satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being "bothered" by others denotes improvement in the patient's condition. The other options suggest that the patient is in danger of relapse.

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

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

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

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This patient now requires persistent direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of: b. dependency caused by institutionalization.

ANS: B Institutions tend to impede independent functioning; for example, daily activities are planned and directed by staff; others provide meals and only at set times. Over time, patients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these patients return to the community, many continue to demonstrate passive behaviors despite efforts to promote. Cognitive dysfunction and antipsychotic side effects can make planning and carrying out activities more difficult, but the question is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead.

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

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? b. Affect flat; mood depressed

ANS: B Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.

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

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: b. hypertensive crisis.

ANS: 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.

A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? b. "You're wearing a new shirt."

ANS: B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (non-therapeutic techniques). Saying "You must be feeling better today" is an assumption, which is non-therapeutic.

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

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

Many persons brought before a criminal court have mental illness, have committed minor offenses, and are off medications. The judge consults the nurse at the local community mental health center for guidance about how to respond when handling such cases. Which advice from the nurse would be most appropriate? b. "Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses."

ANS: B Research supports the use of special mental health courts that can sentence mentally ill persons to treatment instead of jail. Jail exposes vulnerable mentally ill persons to criminals, victimization, and high levels of stimulation and stress. Incarceration can also interrupt eligibility for benefits or lead to the loss of housing and often provides lower-quality mental health treatment in other settings. Recidivism rates for both mentally ill and non-mentally ill offenders are relatively high, so it does not appear that incarceration necessarily leads people to behave more appropriately. In addition, a criminal record can leave them more desperate and with fewer options after release. Research indicates that outpatient commitment is less effective at improving the mental health of mentally ill persons than was expected.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

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

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

For patients diagnosed with serious mental illness, what is the major advantage of case management? b. With one coordinator of services, resources can be more efficiently used.

ANS: B The case manager coordinates the care and multiple referrals that so often confuse the seriously mentally ill patient and the patient's family. Case management promotes efficient use of services. The other options are lesser advantages or are irrelevant.

The sibling of a patient who was diagnosed with a serious mental illness asks why a case manager has been assigned. The nurse's reply should cite the major advantage of the use of case management as: b. "Case managers coordinate services and help with accessing them, making sure the patient's needs are met."

ANS: B The case manager helps the patient gain entrance into the system of care, can coordinate multiple referrals that so often confuse the seriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess the credentials needed to provide psychotherapy or function as therapists. Case management promotes efficient use of services in general, but only Assertive Community Treatment (ACT) programming has been shown to reduce hospitalization (which the sibling might see as a disadvantage). Case managers operate in the community, but this is not the primary advantage of their services.

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

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

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

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

A patient diagnosed with a serious mental illness died suddenly at age 52. The patient lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, "How could this happen?" Which response by the nurse accurately reflects research and addresses the family's question? b. "Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight."

ANS: B The family is in distress. Because they do not understand his death, they are less able to accept it and seek specific information to help them understand what happened. Persons with serious mental illness die an average of 25 years prematurely. Contributing factors include failing to provide for their own health needs (e.g. forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma. The most accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff would not have been surprised that the patient died prematurely, and they would not attribute his death to random, undetected medical problems. Although the cause of death will not be reliably established until the autopsy, this response fails to address the family's need for information.

A patient living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the patient was prohibited from returning to the apartment. The landlord said, "You cause too much trouble." What problem is the patient experiencing? b. Stigma

ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data do not suggest that the patient is actually homeless. See relationship to audience response question.

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

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

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

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? b. "I might be a little dizzy or have a mild headache after each procedure."

ANS: B Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.

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

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

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

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

Select all that apply. A person diagnosed with serious mental illness has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk of stressors to cause relapse? b. Develop written plans that will help the patient remember what to do in a crisis. c. Help the patient identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the patient to a National Alliance on Mental Illness support group.

ANS: B, C, D, E Basic interventions for coping with crises involve anticipating crises where possible and then developing a plan with specific actions to take when faced with an overwhelming stressor. Written plans are helpful; it can be difficult for anyone, especially a person with cognitive or memory impairments, to develop or remember steps to take when under overwhelming stress. Health-promoting activities enhance a person's ability to cope with stress. As the name suggests, support groups help a person develop a support system, and they provide practical guidance from peers who learned from experience how to deal with issues the patient may be facing. Groups and volunteer work may involve a measure of stress but also provide benefits that help persons cope and should not be discouraged unless they are being done to excess.

Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness? c. Assertive Community Treatment (ACT)

ANS: C Assertive community treatment (ACT) involves consumers working with a multidisciplinary team that provides a comprehensive array of services. At least one member of the team is available 24 hours a day for crisis needs, and the emphasis is on treating the patient within his own environment.

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: c. cognitive behavioral therapy.

ANS: C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.

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

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: c. teach the patient strategies to manage postural hypotension.

ANS: C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: c. explain the time lag before antidepressants relieve symptoms.

ANS: C Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.

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

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

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

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

The nurse wants to enroll a patient with poor social skills in a training program for patients diagnosed with schizophrenia. Which description accurately describes social skills training? c. Complex interpersonal skills are taught by breaking them into simpler behaviors.

ANS: C In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. The other distracters are less relevant to social skills training.

Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness who is homeless? c. Chronic low self-esteem

ANS: C Many individuals with serious mental illness do not live with their families and become homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Substance abuse is not an approved NANDA-International diagnosis. Insomnia may be noted in some patients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.

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

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy.

ANS: C Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: c. reporting increased suicidal thoughts.

ANS: C Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider."

ANS: C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.

An adult diagnosed with a serious mental illness says, "I do not need help with money management. I have excellent ideas about investments." This patient usually does not have money to buy groceries by the middle of the month. The nurse assesses the patient as demonstrating: c. anosognosia.

ANS: C The patient scenario describes anosognosia, the inability to recognize one's deficits due to one's illness. The patient is not projecting an undesirable thought or emotion from himself onto others. He is not justifying his behavior via rationalization and is not identifying with another.

Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? c. Situational low self-esteem

ANS: C The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.

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

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

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

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

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

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

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

ANS: C, D, E Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

Select all that apply. A person diagnosed with a serious mental illness (SMI) living in the community was punched, pushed to the ground, and robbed of $7 during the day on a public street. Which statements about violence and serious mental illness in general are accurate? c. Impaired judgment and social skills can provoke hostile or assaultive behavior. d. Lower incomes force SMI persons to live in high-crime areas, increasing risk. e. SMI persons experience higher rates of sexual assault and victimization than others. f. Criminals may believe SMI persons are less likely to resist or testify against them.

ANS: C, D, E, F Mentally ill persons are more likely to be victims of crime than perpetrators of criminal acts. They are often victims of criminal behavior, including sexual crimes, at a higher rate than others. When a mentally ill person commits a crime, it is usually nonviolent. Mental illnesses interfere with employment and are associated with poverty, limiting SMI persons to living in inexpensive areas that also tend to be higher-crime areas. SMI persons may inadvertently provoke others because of poor judgment or socially inappropriate behavior, or they may be victimized because they are perceived as passive, less likely to resist, and less likely to be believed as witnesses. See related audience response question.

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

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? d. Urinary retention

ANS: D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A homeless individual diagnosed with serious mental illness, anosognosia, and a history of persistent treatment nonadherence is persuaded to come to the day program at a community mental health center. Which intervention should be the team's initial focus? d. Interact regularly and supportively without trying to change the patient.

ANS: D Given the history of treatment nonadherence and the difficulty achieving other goals until psychiatrically stable and adherent, getting the patient to accept and adhere to treatment is the fundamental goal to address. The intervention most likely to help meet that goal at this stage is developing a trusting relationship with the patient. Interacting regularly, supportively, and without demands is likely to build the necessary trust and relationships that will be the foundation for all other interventions later on. No data here suggest the patient is in crisis, so it is possible to proceed slowly and build this foundation of trust.

A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? d. Milk

ANS: D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? d. Eyes pointed downward

ANS: D Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.

A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: d. ineffectiveness and frustration.

ANS: D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient's resistance. Guilt and despair might be seen when the nurse experiences the patient's feelings because of empathy. Interest is possible, but not the most likely result.

A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: d. confers with a pharmacist when selecting over-the-counter medications.

ANS: D Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

A patient diagnosed with schizophrenia has had multiple relapses. The patient usually responds quickly to antipsychotic medication but soon discontinues the medication. Discharge plans include follow-up at the mental health center, group home placement, and a psychosocial day program. Which strategy should apply as the patient transitions from hospital to community? d. Involve the patient in decisions about which medication is best.

ANS: D Persons with schizophrenia are at high risk for treatment nonadherence, so the strategy needs primarily to address that risk. Of the options here, involving the patient in the decision is best because it will build trust and help establish a therapeutic alliance with care providers, an essential foundation to adherence. Intramuscular depot medications can be helpful for promoting adherence if other alternatives have been unsuccessful, but IM medications are painful and may jeopardize the patient's acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers.

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

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

ANS: D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.

The parent of a seriously mentally ill adult asks the nurse, "Why are you making a referral to a vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? d. "Most patients are capable of employment at some level, competitive or supported."

ANS: D Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.

A family discusses the impact of a seriously mental ill member. Insurance partially covered treatment expenses, but the family spent much of their savings for care. The patient's sibling says, "My parents have no time for me." The parents are concerned that when they are older, there will be no one to care for the patient. Which response by the nurse would be most helpful? d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the patient become more independent.

ANS: D The family has raised a number of concerns, but the major issues appear to be the effects caregiving has had on the family and their concerns about the patient's future. The National Alliance on Mental Illness (NAMI) offers support, education, resources, and access to other families who have experience with the issues now facing this family. NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the patient's symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. The family will need more than financial planning; their issues go beyond financial. The family is distressed but not in crisis. Crisis intervention is not an appropriate resource for the longer-term issues and needs affecting this family.

An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The patient says, "I threw away the pills because they keep me from hearing God." Which response by the nurse would most likely to benefit this patient? d. "I noticed that when you take the medicine, you have been able to hold a job you wanted."

ANS: D The patient appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinations—the voice of God). Connecting medication adherence to one of the patient's goals (the job) can serve to motivate the patient to take the medication and override concerns about losing the hallucinations. Exhorting a patient to take medication because it is needed to control his illness is unlikely to be successful; he does not believe he has an illness. Medication psychoeducation would be appropriate if the cause of nonadherence was a knowledge deficit.

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

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

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

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

A patient diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the etiology of the patient's ineffective management of the medication regime as: d. impaired reasoning secondary to the schizophrenia.

ANS: D The patient's ineffective management of the medication regime is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest any of the other factors often related to medication nonadherence.

An outpatient diagnosed with schizophrenia tells the nurse, "I am here to save the world. I threw away the pills because they make God go away." The nurse identifies the patient's reason for medication nonadherence as: d. lack of insight associated with the illness.

ANS: D The patient's nonadherence is most closely related to lack of insight into his illness. The patient believes he is an exalted personage who hears God's voice rather than an individual with a serious mental disorder who needs medication to control his symptoms. While the distracters may play a part in the patient's nonadherence, the correct response is most likely.

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: d. firmly and neutrally assist the patient with showering.

ANS: D When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

Two process that contribute to cell death with AD

Accumulation of the protein B-amyloid outside the neurons (known as amyloid plague), which interferes with synapse. The plagues develop in areas of the brain used for memory and cognitive function including the hypothalamus

The nurse caring for a client diagnosed with Alzheimer's disease can anticipate that the family will need information about which medication therapy? Antihypertensives Benzodiazepines Immunosuppressants Acetylcholinesterase inhibitors

Acetylcholinesterase inhibitors (Memory deficit is thought to be related to a lack of acetylcholine at the synaptic level. Acetylcholinesterase inhibitor drugs prevent the chemical that destroys acetylcholine from acting, thus leaving more available acetylcholine.)

The physician mentions to the nurse that a client who is about to be admitted has "sundowning." The nurse can expect to assess for which nightly behavior? Agitation Lethargy Depression Mania

Agitation

A 78-year-old patient diagnosed with Alzheimer's disease picks up a glass from the bedside table but does not recognize the purpose of the object. This inability is associated with which characteristic of the disorder? Apraxia Agnosia Aphasia Agraphia

Agnosia

A client diagnosed with Alzheimer's disease looks confused and cannot recall many common household objects by name, such as a pencil or glass. The nurse should document this loss of function using which term? Apraxia Agnosia Aphasia Anhedonia

Agnosia

What is the most common form of dementia?

Alzheimer's disease

Which type of dementia has a clear genetic link? Alcohol-induced dementia Multi-infarct dementia Creutzfeldt-Jakob disease Alzheimer's disease

Alzheimer's disease

dementia is due to

Alzheimer's disease Frontotemporal Lewy bodies Vascular Traumatic brain injury Substances HIV infection Prior disease Parkinson's disease Huntington's disease Medical condition

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

B Giving information in a calm, simple manner will help the patient grasp the important facts. Introducing extraneous topics as described in the distracters will further scatter the patient's attention.

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

B Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, patients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.

consider these phenomena: accumulation of B-amyloid outside the neurons, neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. which health problem corresponds to these events? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

B

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

B A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.

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

B A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Use of defense mechanisms does not apply.

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

B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.

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

B Because obsessive-compulsive patients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping. Daily activities prevent constant focus on anxiety and symptoms. The other interventions focus on the compulsive symptom. See relationship to audience response question.

A woman is 5'7", 160 lbs, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a.Social anxiety disorder b.Body dysmorphic disorder c.Separation anxiety disorder d.Obsessive-compulsive disorder due to a medical condition

B Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient's feet are proportional to the rest of the body. In obsessive-compulsive or related disorder due to a medical condition, the individual's symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.

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

B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

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

B Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

B (A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.)

Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

B (All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.)

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

B (Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety.)

During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

B (Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.)

A patient with stage 3 (mild) Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

B (Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.)

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

B (Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety.)

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

B (Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.)

Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

B (The listed health problems are all forms of dementia.)

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

B (Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.)

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

B, D, E The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia. See relationship to audience response question.

Neuronal Degeneration (AD)

Begins in the hippocampus, this is part of the brain that is responsible for recent memory, and then spreads into the cerebral cortex, the part of the brain responsible for solving problems and high cognitive function.

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

C (Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease)

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. sundowning b. early c. middle d. late

C

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

C Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.

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

C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is non-therapeutic; the patient likely does not have an answer. The patient may be unable to determine what he or she would like the nurse to do in order to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.

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

C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for anxiety relief. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior. See relationship to audience response question.

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

C Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

A patient tells a nurse, "My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she's had." This patient is demonstrating a. denial. b. projection. c. rationalization. d. compensation.

C Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

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

C Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. The distracters indicate some measure of acceptance of responsibility for the behavior.

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

C Safety needs of the patient and other patients are a priority. Comments to the patient should be simple, neutral, and give direction to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member may be needed to provide physical limits, but using seclusion or physically restraining the patient prematurely is unjustified. Asking the patient to give an example would be futile; a patient in panic processes information poorly.

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

C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

C (Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.)

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

C (Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.)

11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

C (In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.)

Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

C (Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.)

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

C (The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.)

Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

C, D, E (The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.)

Risk Factors for AD

Cardiovascular Disease: including inactivity, high cholesterol, diabetes, and obesity Socially inactive and not consuming a healthy diet Head Injury and Traumatic Brain Injury: (Boxers and football players) Individuals who suffer brain injury and carry the gene APOE E4 are even at a higher risk of developing AD

Medications for AD

Cholinestrase Inhibitors -Tacrine (Cognex) -Donepezil (Aricept) -Rivastigmine (Exelon) -Galanstamine (Razadyne) -N-methyl-d-aspartate (NMDA) Antagonist -Memantine (Namenda, Namenda XR) Antidepressants- SSRI's -Citalopram (Celexa) -Escitalopram (Lexapro) -Fluoxetine (Prozac) -Paroxetine (Paxil) -Setralie (Zoloft) Antianxiety -Lorazepam (Ativan) -Oxazepam (Serax) Antipsychotics -Aripiprazole (Abilify) -Olanzapine (Zyprexa) -Quetiapine (Seroquel) -Risperidone (Risperdal) -Ziprasidone (Geodon) Anticonvulsants -Carbamazepine (Tegretol) -Divalproex (Depakote)

who is Alzheimer disease most common in

Common in individuals 65 years of age and older Both men and women and various ethnicities 44% of people with AD are between the age of 75 and 84 years old 46% are 85 years old or older Globally estimated that 24.3 million people have dementia, and the number will double every 20 years to 81.1 million by 2040

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

D Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.

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

D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.

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

D Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.

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

D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another.

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

D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. See relationship to audience response question.

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

D Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.

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

D Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.

A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

D (Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.)

What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

D (In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.)

A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

D (Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.)

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

D (When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.)

A 62-year-old patient who is recovering from a urinary tract infection that has required hospitalized for delirium. Based on research regarding possible postdelirium complications, what are important areas for the provider to assess regularly after discharge? Sleeping habits Sexual functioning Symptoms of posttraumatic stress Depression and level of cognition

Depression and level of cognition

The family members of a client with early-stage Alzheimer's disease cannot provide adequate supervision for the client. What would be a reasonable alternative for the nurse to explore with them to meet their current needs? Day care Acute care hospitalization Long-term institutionalization Group home residency

Day care

When preparing educational materials for the family of a client diagnosed with progressive dementia, the nurse should include information related to which local resourses? Select all that apply. Day care centers Legal professionals Home health services Family support groups Professional counseling

Day care centers Home health services Family support groups Professional counseling

A family member reports that the client had been oriented and able to carry on a logical conversation last evening, but this morning is confused and disoriented. The nurse can suspect that the client is displaying symptoms associated with which cognitive disorder? Delirium Dementia Amnesic disorder Selective inattention

Delirium

The nurse is expected to perform an assessment of a client suspected to be in the earliest stage of Alzheimer's disease. What finding would be out of character for the client who truly has early stage Alzheimer's disease? Select all that apply. Easily frustrated by cognitive losses Charming behavior designed to hide memory deficit Confabulation to compensate for forgotten information Avoidance of questions by subject changing

Easily frustrated by cognitive losses

A client diagnosed with delirium strikes out at a staff member. The nurse can most correctly hypothesize that this behavior is related to which characteristic symptom of delirium? Anger Fear Unmet physical need Unmet social interaction

Fear

When a delirious client insists that a vacuum hose is a large, poisonous snake, the nurse recognizes that this client is experiencing what characteristic symptom? Hallucinations Illusion Hypervigilant Agnosia

Illusion

What initial intervention should the nurse suggest to the family members of a client diagnosed with Alzheimer's disease who has become incontinence of urine? Label the bathroom door with a picture. Provide toileting on an as-needed basis. Apply disposable diapers. Encourage hourly toileting. Submit

Label the bathroom door with a picture.

what are the form of dementia

Mild neurocognitive disorders Major neurocognitive disorders

Nursing Process-Delirium

Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance. Use restraints as needed Perform comprehensive nursing assessment to aid in identifying cause. Monitor LOC on an ongoing basis. Assist with proper health management to eradicate underlying cause. Use supportive measures to relieve distress. Provide unconditional positive regard. Limit decision making. Maintain a well lit and hazard free environment.

The term "perceptual disturbance" refers to difficulty in which area of function? Processing information about one's internal and external environment Can be one's way of thinking to accommodate new information Performing purposeful motor movements Formulating words appropriately

Processing information about one's internal and external environment

A student nurse is working with an 82-year-old patient diagnosed with dementia. The student is frustrated at times by not knowing how best to care for or communicate with the client. Which of the statement by the student best illustrates best care practice? Lighthearted banter: "Carl, you look great today in your new sweater, you handsome devil!" Limit setting: "Carl, you cannot yell out in your room. You are upsetting other patients." Firm direction: "You will take a shower this morning; there is no debating about it so don't try to argue." Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

Positive regard: "Carl, I am glad to be here caring for you today. Let's talk about your plans for the day."

Which event would an older client diagnosed with early stage Alzheimer's disease have greatest difficulty remembering? His or her high school graduation The births of his or her children The story of a teenage escapade What he or she ate for breakfast

What he or she ate for breakfast

2. Which statement made by a family member tends to support a diagnosis of delirium rather thandementia? a. "She was fine last night but this morning she was confused." b. "Dad doesn't seem to recognize us anymore." c. "She's convinced that snakes come into her room at night." d. "He can't remember when to take his pills or whether he's bathed."

a

5. What is the rationale for providing a patient diagnosed with dementia easily accessible finger foodsthorough the day? a. Increases input throughout the day b. The person may be anorexic c. Assists with monitoring food intake d. Helps prevent constipation

a

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

a

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

a

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

a

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

a

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

a

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

a

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

a

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

a

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

a

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

a

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

a, b

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

a, e

4. What side effects should the nurse monitor for when caring for a patient prescribed donepezil (Aricept)?Select all that apply. a. Insomnia b. Constipation c. Bradycardia d. Signs of dizziness e. Reports of headache

a,c,d,e

10. Nurses caring for patients who have neurocognitive disorders are exposed to stress on many levels.Specialized skills training and continuing education are helpful to diffuse nursing stress, as well as: Select all that apply. a. Expressing emotions by journaling b. Describing stressful events on Facebook c. Engage in exercise and relaxation activities d. Having realistic patient expectations e. Happy hour after work to blow off steam

a,c.d

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

b

Illusions is

are errors in perception of sensory stimuli. A person may mistake folds in the blanket for white rats or the cord of a window blind for a snake.

Hallucinations are

are false sensory stimuli. Visual hallucinations are common in delirium, although tactile hallucinations may also be present

3. When considering the pathophysiology responsible for both delirium and dementia, which intervention isappropriate for delirium specifically? a. Assist with needs related to nutrition, elimination, hydration, and personal hygiene. b. Monitor neurological status on an ongoing basis. c. Place identification bracelet on patient. d. Give one simple direction at a time in a respectful tone of voice.

b

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

b

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

b

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tar dive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

b

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

b

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

b

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

b

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

b

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

b

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

b

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

b

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

b

1. Which statement made by the primary caregiver of a patient diagnosed with dementia demonstratesaccurate understanding of providing the patient with a safe environment? a. "The local police know that he has wandered off before." b. "I keep the noise level low in the house." c. "We've installed locks on all the outside doors." d. "Our telephone number is always attached to the inside of his shirt pocket."

c

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

c

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

c

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

c

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

c

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

c

Confabulation is

creation of stories or answers in place of actual memories to maintain self esteem

1. Ophelia, a 69-year-old retired nurse, attends a reunion of her former coworkers. Ophelia is concernedbecause she usually knows everyone, and she cannot recognize faces today. A registered nurse colleague recognizes Ophelia's distress and "introduces" Ophelia to those attending. The nurse practitioner recognizes that Ophelia seems to have a deficit in: a. Lower-level cognitive domain b. Delirium threshold c. Executive function d. Social cognition

d

8. Darnell is an 84-year-old widower who has lived alone since his wife died 6 years ago. A neighbor calledDarnell's son to tell him that Darnell was trying to start his car from the passenger's side. He became angry and aggressive when the car would not start. After a medical assessment, Darnell was diagnosed with a major neurocognitive disorder. The nurse realized additional family teaching is necessary when Darnell's son states: a. "My father's diagnosis is interfering with his daily functioning." b. "This neurocognitive disorder will probably progress." c. "Advancing age is a risk factor in my father's diagnosis." d. "With person-centered care, my father will be able to remain in his home."

d

9. In the 2 months after his wife's death, Aaron, aged 90 and in good health, has begun to pay less attentionto his hygiene and seems less alert to his surroundings. He complains of difficulty concentrating and sleeping and reports that he lacks energy. His family sometimes has to remind and encourage him to shower, take his medications, and eat, all of which he then does. Which response is most appropriate? a. Reorient Mr. Smith by pointing out the day and date each time you have occasion to interact with him. b. Meet with family and support them to accept, anticipate, and prepare for the progression of his stage 2dementia. c. Avoid touch and proximity; these are likely to be uncomfortable for Mr. Smith and may provokeaggression when he is disoriented. d. Arrange for an appointment with a therapist for evaluation and treatment of suspected depression.

d

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

d

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

d

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

d

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

d

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

d

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

d

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

d

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

d

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

d

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

d

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

d

A 72-year-old patient is hospitalized diagnosed with pneumonia and experiencing delirium. When the client points to the IV pole and screams, "Get him out of here! He's going to hurt me!", the nurse recognizes the response as a(n) hallucination. delusion. illusion. confabulation.

illusion.

Apraxia is

inability to perform purposeful movements-needs repeated concise instructions to perform simple tasks

Agraphia is

inability to read or write

Aphasia is

inability to understand or express speech

Hyperorality is

need to taste, chew, and put everything in one's mouth.

Perseveration is

repeating phrases or behavior

A nursing diagnosis appropriate for a client with Alzheimer's disease, regardless of the stage, would be risk for injury. acute confusion. imbalanced nutrition. impaired environmental interpretation syndrome.

risk for injury.

Hypermetamorphosis is

touching everything in sight

Agnosia is

unable to identify familiar objects