Psych Final Study
A client has been evaluated for emergency commitment because of the likelihood the client will do serious harm to others. The client threatened to kill his neighbor because he is plotting "against him." In assessing the need for commitment, what *opening* would be most facilitative of communication? a "Tell me about your delusions." b "I understand you have had some difficulty today." c "You have threatened your mother. Tell me why." d "Because you threatened your mother, you are going to have to go to the hospital."
"I understand you have had some difficulty today."
The staff on a psychiatric unit observes a new nurse expressing anger and distrust while treating a client with a long history of alcoholism. The staff suspects that the nurse is using countertransference. Which statement by the nurse would indicate that the staff is correct? 1. "My mother was an alcoholic and neglected her family." 2. "The client said I had the same disposition as his cranky wife." 3. "Maybe the client and I can sit down and work out a plan." 4. "The client refuses to accept responsibility for his alcoholism."
1. In this example, countertransference refers to the nurse's behavioral and emotional response to the client's alcoholism. These feelings may be related to unresolved feelings toward significant others from the nurse's past, or they may be generated in response to transference feelings on the part of the client.
Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? 1. Modify environment to decrease stimulation and provide opportunities for quiet reflection. 2. Convey unconditional acceptance and positive regard. 3. Recognize escalating aggressive behavior and intervene before violence occurs. 4. Provide immediate positive feedback for appropriate behaviors.
3- The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behavior and to intervene before violence occurs. This intervention serves to keep the client as well as others safe, which is the priority nursing concern.
Lithium carbonate (lithium) is to mania as clozapine (Clozaril) is to: 1. Anxiety. 2. Depression. 3. Psychosis. 4. Akathisia.
3. Clozapine (Clozaril), an atypical antipsychotic, is used to treat symptoms of thought disorders, such as, but not limited to, psychoses
On an in-patient psychiatric unit, the nurse helps the client practice various techniques of assertive communication and gives positive feedback for attempting to improve passive-aggressive interactions. This interaction would occur in which phase of the nurse-client relationship? 1. Pre-interaction phase. 2. Orientation (introductory) phase. 3. Working phase. 4. Termination phase.
3. The working phase includes promoting the client's insight and perception of reality, problem solving, overcoming resistant behaviors, and continuously evaluating progress toward goal attainment. In this example, the client works toward better communication and is guided and encouraged with positive feedback by the nurse. Goal: Promote client change.
Japanese client who has been in US for 1 year is admitted to hospital. You are to compete admission history. What is 1st action you should take to ensure culturally appropriate care? 1. Using simple sentences and avoiding long explanations. 2. Speaking to the client as though the client could hear. 3. Listening attentively, allowing time, and not interrupting. 4. Assess fluency of English
4 assess fluency of English
The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.
A. Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. The potential for self-violence or other-directed violence may or may not be a factor in crisis.
Woman seeks help because she is distraught over her daughter going to college and her having an empty nest. This is an example of which type of crisis? A: maturational B:situational C.menopausal
A: maturational crisis
During a mental status examination, the nurse wants to assess a patient's mood. The nurse should ask the patient which question? A. "How do you feel today?" B. "What is your mood?" C. "Can you tell me if you are happy or depressed?" D. "Can you rate your mood 1-10?"
B. "What is your mood?" Judge mood and affect by body language and facial expression and by asking directly, "What is your mood?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.
Nurse Ebony is aware that the drug of choice for treating Tourette syndrome? a. fluoxetine (Prozac) b. fluvoxamine (Luvox) c. haloperidol (Haldol) d. paroxetine (Paxil)
Explanation: c Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome
When the nurse creates an environment to facilitate healing, the nurse's actions are based on which of the following assumptions? Select all that apply. 1. A therapeutic relationship can be a healing experience. 2. A healthy relationship cannot be transferred to other relationships. 3. Group settings can support ego strengths. 4. Treatment plans can be formulated by observing social behaviors. 5. Promoting countertransference eases the establishment of the nurse-client relationship.
1,3, 4 CORRECT 1. A therapeutic relationship is characterized by rapport, genuineness, and respect, and can be a healing experience. 3. Group processes provide learning experiences and support a client's ego strengths. 4. During group processes and interactions, staff members can observe social behaviors, and this can determine client needs. Treatment plans can be customized to these needs. INCORRECT: 2. A healthy relationship can be a prototype for other health relationships. 5. Countertransference refers to the nurse's behavioral and emotional response to the client. Unresolved feelings toward significant others from the nurse's past may be projected to the client. *Countertransference is a hindrance to the establishment of the nurseclient relationship.*
A nurse is performing a general assessment of adolescents in a school to identify students with conduct disorder. Which students are likely to be identified with the condition, based on the nurse's assessment? Select all that apply. 1 A student who repeatedly bullies younger students 2 A student getting bad grades in a class 3 A student who is constantly involved in activities resulting in damage to school property 4 A student who had a fight with a classmate 5 A student who always uses abusive language while speaking to teachers
1,3,5 Conduct disorder is characterized by persistent behavior that violates societal norms, rules, laws, and the rights of other people. The disorder could be in the form of aggression toward people and animals, destruction of property, deceitfulness and theft, and/or serious violation of rules. A student who persistently abuses younger children may be classified as having conduct disorder. A student who is constantly involved in activities that result in damage to school property (destruction of property) may have conduct disorder. A student who constantly uses extremely abusive language while speaking to teachers (aggression toward people) also may have conduct disorder. Having a fight with a classmate and getting bad grades in a class are not abnormal behavior in adolescents.
In a psychiatric in-patient setting, the nurse observes an adolescent crying after the client's peers were calling the client names. Which statement by the nurse exemplifies the concept of empathy? 1. "I can see that you are upset. Tell me how you feel." 2. "Your peers are being insensitive. I would be upset also." 3. "I used to be called names as a child. I know it can hurt feelings." 4. "I get angry when people are treated cruelly."
1. This empathetic statement appreciates the client's feelings and objectively communicates concern for the client. In an empathetic response the nurse exhibits warmth and *acknowledges the patient's feelings* Commenting on the patient's crying is an example of the technique of making observations.
Which responses should the nurse document as indicating pseudoparkinsonism? (Select all that apply.) 1.Rigidity 2.Tremors 3.Mydriasis 4.Photophobia 5.Bradykinesia 6.Shuffling gait
1.Rigidity 2.Tremors 5.Bradykinesia 6.Shuffling gait Rigidity, tremors, Shuffling gait and bradykinesia may occur because of the effect of the antipsychotic drugs on dopamine receptors in the brain. Mydriasis and photophobia are not side effects of antipsychotic drugs.
In which situation would benzodiazepines be prescribed appropriately? 1. Long-term treatment of posttraumatic stress disorder, convulsive disorder, and alcohol withdrawal. 2. Short-term treatment of generalized anxiety disorder, alcohol withdrawal, and preoperative sedation. 3. Short-term treatment of obsessive-compulsive disorder, skeletal muscle spasms, and essential hypertension. 4. Long-term treatment of panic disorder, alcohol dependence, and bipolar affective disorder: manic episode.
2 Benzodiazepines are prescribed for short term treatment of generalized anxiety disorder and alcohol withdrawal, and can be prescribed during preoperative sedation.used to decrease anxiety symptoms. They are not intended to be prescribed for long-term treatment. They can be prescribed for individuals diagnosed with posttraumatic stress disorder, convulsive disorder, and alcohol withdrawal.
On an in-patient psychiatric unit, a client states, "I want to learn better ways to handle my anger." This interaction is most likely to occur in which phase of the nurse-client relationship? 1. Pre-interaction phase. 2. Orientation phase. 3. Working phase. 4. Termination phase.
2. The orientation (introductory) phase involves creating an environment that establishes trust and rapport. Another task of this phase includes establishing a contract for interventions that details the expectations and responsibilities of the nurse and the client. In this example, the client has built the needed trust and rapport with the nurse. The client now feels comfortable and ready to acknowledge the problem and contract for intervention. Goal: Establish trust and formulate contract for intervention.
While talking about an abusive childhood, a client suddenly blurts out, "I hate my doctor." Which client statement would indicate that resistance is taking place? 1. "The doctor has told me that his son recovered, and I will also." 2. "I don't care what anyone says, I don't have a problem I can't handle." 3. "I'd bet my doctor beat and locked his son in a closet when he was a boy." 4. "I'm going to stop fighting and start working together with my doctor."
2. This is an example of resistance which is often caused by the client's unwillingness to change when the need for change is recognized. It also involves the client's reluctance or avoidance of verbalizing or experiencing troubling aspects of the client's life.
Which best exemplifies the use of the defense mechanism of sublimation? 1. A child who has been told by parents that stealing is wrong reminds a friend not to steal. 2. A man who loves sports but is unable to play decides to become an athletic trainer. 3. Having chronic asthma with frequent hospitalizations, a young girl admires her nurses. She later chooses nursing as a career. 4. A boy who feels angry and hostile decides to become a therapist to help others.
4. Directing hostile feelings into productive activities, such as becoming a therapist to help others, *is an example of the defense mechanism of sublimation*. Sublimation is the method of rechanneling drives or impulses that are personally or socially unacceptable into activities that are constructive.
A client is admitted to the emergency department after a car accident, but does not remember anything about it. The client is using which defense mechanism? 1. Undoing. 2. Rationalization. 3. Suppression. 4. Repression.
4. The client in the question is using the defense mechanism of repression. Repression is the *unconscious*, involuntary blocking of unpleasant feelings and experiences from one's own awareness. *Suppression intentionally avoiding thinking about problem areas. Ex- woman going vacation finds out she has cancer and puts it in the back of her mind until back from her vacation*
A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is *unrelated* to an extrapyramidal tract effect? Akathisia Hypertensive crisis
A hypertensive crisis is *not* associated with extrapyramidal tract symptoms. Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, (or kicking legs cant stop them from moving)is an *extrapyramidal side effect.*
A client asks the nurse if he needs to alter any of his activities because he is taking lithium carbonate. Which of the following responses would be most appropriate? A)Increase your salt intake if an activity causes you to perspire heavily. B)Wear sunscreen when you are going to be outdoors in the summer time. C)Drink less fluid than usual now because you are taking this drug. D)No changes are necessary for strenuous activities you do outdoors.
A) Increase your salt intake if an activity causes you to perspire heavily.
A patient being treated for depression reports experiencing nausea, palpitations, and "a terrible headache." When the physical examination determines the patient is diaphoresic and hypertensive, the nurse should ask: a."When did you last take your phenelzine (Nardil)?" b."Did you take your amitriptyline (Elavil) on schedule?" c."What natural foods have you had in the last 24 hours?" d."Have you had any alcohol to drink within the last 24 hours?"
A-Nardil This question requires analytical decision making to identify hypertensive crises and data for the evaluation process. Knowing when the last dose of the monoamine oxidase inhibitor (MAOI) was taken helps determine immediate treatment. The patient is experiencing the clinical manifestation of hypertensive crisis. *The classic symptoms of this condition are severe occipital headache, dilated pupils, hypertension, and palpitations or arrhythmias.* This syndrome can be caused when the patient who is taking an MAOI ingests food containing tyramine, an amino acid released from foods that undergo hydrolysis (e.g., fermentation, aging, pickling, smoking, spoilage). This inhibits the monoamine oxidase and allows tyramine to reach the adrenergic nerve endings and cause the release of excess norepinephrine, which causes hypertensive crisis. To confirm the physical syndrome, first determine whether the patient is taking an MAOI.
A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.
ANS: 1 Rationale: The nurse should determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.
A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.
ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient's personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.
A person who is speaking about a contender for a significant other's affection says in a gushy, 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.
ANS: 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 patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.
ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. *know that anxiety has gone from moderate to Panic-level when anxiety results in disorganized behavior!*
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 fluids. 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 developing lithium toxicity. The incorrect options offer inappropriate information.
A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on: a. supporting emotional security and reestablishing equilibrium. b. offering long-term resolution of issues precipitating the crisis. c. promoting growth of the individual. d. providing legal assistance.
ANS: A Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and reestablishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the pre-crisis level of function.
A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing .
ANS: A The 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 statement is an example of an inference? a. "She states he binges after eating." b. "She is a shopaholic because her spouse is rich." c."You say you smoke 2 packs of cigarettes a day?" d."So you are saying that nursing school sucks ass?"
ANS: B An inference is an interpretation of behavior that is made by finding motive and forming conclusions *without having all the necessary information*. The nurse interprets the patient's behavior, decides on a reason, assigns a motive, and forms a conclusion. The remaining options are validations of observations.
Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can
ANS: B The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is a danger to self and requires emergency treatment.
An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by two security guards and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."
ANS: B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability.
During a psychoeducational group on assertiveness training a client asks, "Why do we need to learn about this stuff?" Which is the most appropriate nursing reply? A. "Because your doctor requires you to attend this group." B. "Being assertive is the ability to stand up for yourself while respecting the rights of others." C. "Assertiveness training teaches you how to ask for what you want, when you want it." D. "Assertive people place the needs and rights of others before their own."
ANS: B Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others.
A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What are they going to do?" Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
ANS: B Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.
ANS: B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. *Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide* Distributing limited amounts of the medication decreases this potential.
A client is admitted to a psychiatric unit with the diagnosis of schizophrenia. Which of the client's neurotransmitters should a nurse Amy expect to be elevated? A. Serotonin B. Dopamine C. Gamma-aminobutyric acid (GABA) D. Histamine
ANS: B The nurse should expect that elevated dopamine levels might be an attributing factor to the client's current level of functioning. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability.
Which intervention will best help a teenager manage aggressive behavior? a. Administering prescribed medication as ordered b. Supporting the patient's interest in writing poetry c. Reenacting situations that may trigger aggression d. Providing information on anger management techniques
ANS: C Role-play situations that trigger aggressiveness explore and reinforce alternative methods of coping. The other options although appropriate lack the opportunity to reflect on the triggers and practice the coping skills.
A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. I don't hear any voices speaking." D. "The devil only talks to people who are receptive to his influence."
ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination.
Which client diagnosis should a nurse associate with a decrease in gamma-aminobutyric acid (GABA)? A. Alzheimer's disease B. Schizophrenia C. Panic disorder D. Depression
ANS: C The nurse should associate a decrease in GABA with panic disorder. Enhancement of the GABA system is the mechanism of action by which benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the GABA system are also associated with movement disorders and epilepsy.
Which finding indicates that a patient with anxiety has successfully reduced their anxiety level? The patient: a. asks, "What's the matter with me?" b. stays in a room alone and paces rapidly. c. can concentrate on what the nurse is saying. d. states, "I don't want anything to eat. My stomach is upset."
ANS: C Concentration difficulties occur when moderate or greater levels of anxiety are present. The higher the anxiety the less ability to concentrate. Patients with high levels of anxiety often ask, "What's the matter with me?" Staying in a room alone and pacing suggest moderate anxiety. *Concentration difficulties occur when moderate or greater levels of anxiety are present*
A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."
ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
An angry client on an inpatient unit approaches a nurse, stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should be addressed only during group therapy.
ANS: C The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning. *milieu therapy=manipulating the environment to meet the individual's needs* *clients feel a sense of support from one another*
A person has minor physical injuries after an automobile 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 this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic
ANS: 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-level anxiety demonstrates significantly disturbed behavior and may lose touch with reality.
For a patient experiencing panic, which nursing intervention should be implemented first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.
ANS: C Calm, brief, directive verbal interaction can help the patient gain control of the 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 an 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.
While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance.
ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimiaia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia
A patient diagnosed with bipolar disorder is hyperactive and manic 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 de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking "why" does not provide for environmental safety.
A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial
ANS: D Denial 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.
An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority question? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"
ANS: D The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials.
A Haitian patient diagnosed with depression tells the nurse, "There's nothing you can do. This is a punishment. The only thing I can do is see a healer." The culturally aware nurse assesses that the patient: a. has delusions of persecution. b. has likely been misdiagnosed with depression. c. may believe the distress is the result of a curse or spell. d. feels hopeless and helpless related to an unidentified cause.
C Within each culture, many variations and subcultures exist. *Per PPT Voodoo is real to those that believe it & is not psychosis*
The nurse is reviewing the medical records of several patients receiving antipsychotic agents. Which factors, if noted, would the nurse identify as placing a patient at greater risk for tardive dyskinesia? A)Male gender B)Age 30 to 45 years C)History of bipolar depression D)Short duration of treatment
C) History of bipolar depression (long term use) Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication
A patient is brought to the emergency department by her brother, who reports that the patient became very agitated and started hallucinating. Further assessment reveals tachycardia, incoordination, vomiting, and diarrhea. The brother states that the patient is taking paroxetine for depression. Which of the following would the nurse most likely suspect? A)Neuroleptic malignant syndrome B)Acute dystonic reaction C) Serotonin syndrome D)Hypothyroidism
C)Serotonin syndrome Alterations in mental status, restlessness, tachycardia, fluctuating blood pressure, and diaphoresis all are symptoms of serotonin syndrome. If this syndrome were suspected, the offending agent would be discontinued immediately.
A nurse administers a prescribed dose of lithium at 8 PM. The nurse would schedule a specimen to be obtained for a blood level at which time? A)10 PM B)12 AM C)4 AM D)8 AM
D) 8 AM sample taken 8 to 12 hours after the last dose of lithium
A patient who has been taking clozapine for 6 weeks visits the clinic complaining of fever, sore throat, and mouth sores. The nurse notifies the patient's physician because the nurse suspects which of the following? A) Severe anemia B) Neuroleptic malignant syndrome C) Encephalitis D) Agranulocytosis
D) Agranulocytosis Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking clozapine (Clozaril). The nurse should establish a baseline white blood cell count to evaluate for this side effect if clozapine is being considered as a treatment option. *MUST WATCH Clozapine closely!*
Which individual has not met the criteria for involuntary commitment to a mental health facility? A. A teenager who has threatened to shoot himself if his girlfriend leaves him B. A young adult who is 20% below normal weight as a result of dramatically restricting food C. An older adult found wandering in the mall who is unable to provide his name D. An adult who reports that he drinks way too much in order to forget the abuse he's endured
D. An adult who reports that he drinks way too much in order to forget the abuse he's endured. involuntary commitment criteria involves assessing whether the person is in danger of harming him/herself, the person has a plan to harm or is a threat to the safety of another individual or group
If a family member speaks English as well as the patient's native language, and is willing to act as interpreter, this is the best possible solution to the problem of interpreting. T/F?
False: This is an inappropriate responsibility for families to take on. The rationale for using professional interpreters is clear. Professional interpreters have been trained to provide accurate, sensitive two-way communication and uncover areas of uncertainty or discomfort. Family members are often too emotionally involved to tell the patient's story fully and objectively, or lack the technical knowledge to convey the provider's message accurately.)
On an in-patient psychiatric unit, the goals of therapy have been met, but the client cries and states, "I have to keep coming back to therapy to handle my anger better." This interaction occurs in which phase of the nurse-client relationship? 1. Pre-interaction phase. 2. Orientation (introductory) phase. 3. Working phase. 4. Termination phase.
The termination phase occurs when progress has been made toward attainment of mutually set goals, a plan for continuing care is mutually established, and feelings about termination are recognized and explored. In this example, the nurse must establish the reality of separation and resist repeated delays by the client because of dependency needs. Goal: Evaluate goal attainment and ensure therapeutic closure **Evaluation is a task of the termination phase**
A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Michelle should tell the client that the only effective treatment for alcoholism is: a. Psychotherapy b. total abstinence c. Alcoholics Anonymous (AA) d. aversion therapy
Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.
George is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: a. antisocial personality disorder b. borderline personality disorder c. obsessive-compulsive personality disorder d. narcissistic personality disorder
a. The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.
A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder.This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues? a. A rigid posture, restlessness, and glaring b. Depression and physical withdrawal c. Silence and noncompliance d. Hypervigilance and talk of past violent acts
a. A rigid posture, restlessness, and glaring Behavioral clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance.
The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? a. Accept responsibility for own behaviors b. Be able to verbalize own needs and assert rights c. Set firm and consistent limits with the client d. Allow the child to establish his own limits and boundaries
a. Accept responsibility for own behaviors Explanation: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.
Nurse Rachael is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? a. Providing one-on- one supervision during meals and for 1 hour afterward b. Letting the client eat with other clients to create a normal mealtime atmosphere c. Trying to persuade the client to eat and thus restore nutritional balance d. Giving the client as much time to eat as desired
a. Providing one-on- one supervision during meals and for 1 hour afterward Explanation: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on- one supervision during meals and for 1 hour afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat and give attention for not eating. Option C would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat, as in option D, the nurse should set limits and let the client know what is expected.
A male client is hospitalized with fractures of the right femur and right humerus sustained in amotorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, what lab values would be of importance to test for? a. acetate accumulation b. thiamine deficiency c. triglyceride buildup d. a below-normal serum potassium level
b. thiamine deficiency Explanation: Excessive alcohol intake can lead to inadequate intake of vitamin B1 (thiamine) Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms.
Nurse Erika is aware that the following medical conditions is commonly found in clients with bulimia nervosa? a. Allergies b. Cancer c. Heart disease d. Hepatitis A
c. Heart disease Bulimia nervosa can lead to many complications, including heart disease, diabetes, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A
A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time? a. Keeping the client restrained in bed b. Checking the client's blood pressure every 15 minutes and offering juices c. Providing a quiet environment and administering medication as needed and prescribed d. Restraining the client and measuring blood pressure every 30 minutes
c. Providing a quiet environment and administering medication as needed and prescribed Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.
A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? a. Vomiting, diarrhea, and bradycardia b. Dehydration, temperature above 101° F (38.3° C), and pruritus c. Hypertension, diaphoresis, and seizures d. Diaphoresis, tremors, and nervousness
d Explanation: Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.
During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? a. "I trust you not to purge." b. "How are you purging and when do you do it?" c. "Don't worry. I won't allow you to purge today." d. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."
d. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." Explanation: This response acknowledges that the client is testing limits and that the nurse is setting them byperforming postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.
