Psych practice exam 2
A 15 year old female is admitted for treatment of anorexia nervosa. Which of the following is diagnostic of anorexia nervosa? A. Body weight less than 85% of normal for age and height B. Amenorrhea for at least 2 cycles C. Absence of hunger feelings D. Erosion of dental enamel
A with anorexia have a body weight that is 85% or less of that expected for their age and height, have experienced amenorrhea for at least three consecutive cycles, and have a preoccupation with food and food-related activities. These clients do not lose their appetites. They still experience hunger but ignore it and signs of physical weakness and fatigue. Dental erosion is characteristic of bulimia nervosa.
A nurse is orienting to a new position working the infirmary in the state penitentiary. When working with prisoners who are also mentally ill, the nurse examines her own attitudes. Which of the following beliefs should the nurse discuss with her supervisor before caring for incarcerated patients? A. People with mental illness are inherently violent B. The mentally ill can get better treatment in prison than in the community C.People with mental illness are more vulnerable to victimization when incarcerated D. Many mentally ill would not be in prison if they were stabilized on medication
A Although it is true that people with major mental illnesses who do not take prescribed medication are at increased risk for being violent, most people with mental illness do not represent a significant danger to others. Criminalization of mental illness refers to the practice of arresting and prosecuting mentally ill offenders, even for misdemeanors, at a rate four times that of the general population in an effort to contain them in some type of institution where they might receive needed treatment. People with a mental illness are more likely to be the victims of violence, both in prisons and in the community.
hich of the following is believed to be a risk factor specific to the development of delirium A. Co-occurring general medical condition B. Older age C. Baseline cognitive impairment D. Gradual decline in functioning
A An estimated 10% to 15% of people in the hospital for general medical conditions are delirious at any given time. Onset is sudden. Delirium is common in older acutely ill clients. Risk factors for delirium include increased severity of physical illness, older age, and baseline cognitive impairment such as that seen in dementia. Children may be more susceptible to delirium, especially that related to a febrile illness or certain medications such as anticholinergics. Prevalence of dementia also rises with age, and progression is gradual.
The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says, A. "Are you hearing something?" B. "It's a beautiful day, isn't it?" C. "Would you like to go to your room to talk?" D. "Would you like to take some of your PRN medication?"
A Asking the client if he is hearing something validates the nurse's assessment and focuses on the client's experience. Answers B, C, and D do not address the situation of the client experiencing auditory hallucinations at the present time.
A patient calls the emergency department of the local hospital reporting that after 16 years of heavy drinking he is tired and wants to quit "cold turkey". The best response by the nurse would be A."Is there a family member that can bring you in right away? It is not safe to stop drinking suddenly without medicine." B. "You sound really motivated. Come in and we will help you find a treatment center." C."After a few days of rest you should feel much better as long as you do not drink anything." D."You will likely feel anxious and get a severe headache. Treat these symptoms with acetaminophen and rest, and come in if they do not get better in 3-5 days."
A Because alcohol withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision. If the client's withdrawal symptoms are mild and he or she can abstain from alcohol, he or she can be treated safely at home. For more severe withdrawal or for clients who cannot abstain during detoxification, a short admission of 3 to 5 days is the most common setting. Some psychiatric units also admit clients for detoxification, but this is less common.
The nurse is teaching a patient with paranoid personality disorder to validate ideas with another person before taking action on them. Which of the following is the best rationale for this intervention? A. It will assist them to start basing decisions and actions on reality B. It will help them understand the origins of their paranoid thinking C. It will help them learn to trust other people D. It will teach them to differentiate when their suspicions are true
A One of the most effective interventions with paranoid or suspicious clients is helping clients to learn to validate ideas before taking action; however, this requires the ability to trust and to listen to one person. The rationale for this intervention is that clients can avoid problems if they can refrain from taking action until they have validated their ideas with another person. This helps prevent clients from acting on paranoid ideas or beliefs. It also assists them to start basing decisions and actions on reality.
The nurse is teaching a patient with paranoid personality disorder to validate ideas with another person before taking action on them. Which of the following is the best rationale for this intervention? A.It will assist them to start basing decisions and actions on reality B.It will help them understand the origins of their paranoid thinking C. It will help them learn to trust other people D.It will teach them to differentiate when their suspicions are true
A One of the most effective interventions with paranoid or suspicious clients is helping clients to learn to validate ideas before taking action; however, this requires the ability to trust and to listen to one person. The rationale for this intervention is that clients can avoid problems if they can refrain from taking action until they have validated their ideas with another person. This helps prevent clients from acting on paranoid ideas or beliefs. It also assists them to start basing decisions and actions on reality.
The nurse is talking to a client who is having difficulty following the rules of the inpatient unit. A patient says, "Its' been so long since I've been with my family." Which statement by the nurse is an example of restating? A. "You say you haven't seen your family in a while." B. "Tell me when you last saw your family." C. "Go on. Tell me more." D. "When was the last time you saw your family?"
A Restating is repeating the main idea expressed. Focusing is used to concentrate on a specific topic. General leads give encouragement to continue. Placing events in sequence clarifies the relationship of events in time.
A patient with bipolar disorder has a long history of both hospitalizations and incarcerations. The patient has no permanent residence and has infrequent contact with his family. Upon admission to the inpatient psychiatric unit for stabilization, the nurse documents all of the following in the record. Which data most suggests a positive outcome for this patient? A patient with bipolar disorder has a long history of both hospitalizations and incarcerations. The patient has no permanent residence and has infrequent contact with his family. Upon admission to the inpatient psychiatric unit for stabilization, the nurse documents all of the following in the record. Which data most suggests a positive outcome for this patient?
A Results are positive when personal connections with case managers are established. The most recent report from the ACCESS project found frequent shifts between the street, programs, and institutions worsen the lives of the homeless. The degree of social support and employment has direct influence on quality of life.
A patient is admitted for major depression. The nurse should expect to find which of the following in the assessment? A. Anhedonia, feelings of worthlessness, and difficulty focusing B. depressed mood, guilt, pressured speech C. changes in sleep pattern, tired, grandiose mood D. difficulty focusing, feelings of helplessness, flight of ideas
A Symptoms of Major Depressive Disorder include depressed mood, anhedonism (decreased attention to and enjoyment from previously pleasurable activities), unintentional weight change of 5% or more in a month, change in sleep pattern, agitation or psychomotor retardation, tiredness, worthlessness or guilt inappropriate to the situation (possibly delusional), difficulty thinking, focusing, or making decisions, or hopelessness, helplessness, and/or suicidal ideation. Grandiose mood, pressured speech, and flight of ideas are associated with mania.
A patient is admitted for major depression. The nurse should expect to find which of the following in the assessment? A.Anhedonia, feelings of worthlessness, and difficulty focusing B. depressed mood, guilt, pressured speech C. changes in sleep pattern, tired, grandiose mood D. difficulty focusing, feelings of helplessness, flight of ideas
A Symptoms of Major Depressive Disorder include depressed mood, anhedonism (decreased attention to and enjoyment from previously pleasurable activities), unintentional weight change of 5% or more in a month, change in sleep pattern, agitation or psychomotor retardation, tiredness, worthlessness or guilt inappropriate to the situation (possibly delusional), difficulty thinking, focusing, or making decisions, or hopelessness, helplessness, and/or suicidal ideation. Grandiose mood, pressured speech, and flight of ideas are associated with mania.
A client with borderline personality disorder who has transient psychotic episodes involving auditory hallucinations is being discharged to home. Which of the following instructions by the nurse is appropriate for helping the client deal with these episodes? A. Call the clinic and ask to speak to someone. B. Take additional doses of medication until the voices subside. C. Tell yourself, "I'm not really hearing anything." D. Try to sit quietly until the voices subside.
A The client will benefit from talking to a professional who can assist the client during these episodes. Answers B, C, and D are not appropriate instructions to give a client with borderline personality disorder exhibiting hallucinations.
A 16-year-old female with anorexia nervosa is admitted to the unit. The most appropriate short-term outcome is that the client will A. "Has your brother been taking unnecessary risks?" B. "Is your brother sleeping more recently?" C. "Has your brother had intense focus lately." D. "Is your brother showing low self-esteem?"
A The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments.
A depressed patient states, "I think my family would be better off without me. They don't need to worry." The most appropriate response by the nurse would be: A. "Are you planning to commit suicide?" B. "What do you think they are worried about?" C. "Where are you going?" D. "You don't mean that. Your family loves you."
A The nurse never ignores any hint of suicidal ideation regardless of how trivial or subtle it seems and the client's intent or emotional status. Asking clients directly about thoughts of suicide is important.
The nurse is caring for a patient with cognitive impairment. To determine whether the patient is suffering from delirium or dementia, the nurse reviews the symptoms and course of each disorder. Which of the following terms describe delirium? select all apply A. Rapid Onset B. Progressive Decline C. Long-term memory impairment D. Slurred Speech E. Hallucinations
A,D,E Onset of delirium is rapid, dementia is gradual. Duration of delirium is brief, dementia is progressing. Delirium affects only short-term memory. Dementia begins with short-term memory loss and progresses to long-term memory loss. Slurred speech is characteristic of delirium. Speech with dementia is unchanged until the patient begins to develop aphasia. Visual and tactile hallucinations are common with delirium, but rarely experienced with dementia.
A depressed client keeps saying, "I want to kill myself. I have nothing to live for anymore." The nurse would interpret this cue A. Covert B. Overt C. Intentional D. Clear
B
A patient asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication. The best explanation by the nurse would be which of the following? A."The effects of medications will not last forever. You will need to eventually learn to function without them." B."Medications help your brain function better, but the therapy helps you achieve lasting behavior change." C."Both are recommended. Since your insurance covers both that is the best plan for you." D. "You have reservations about going to therapy?"
B Clients and family should know that treatment outcomes are best when psychotherapy and antidepressants are combined. Psychotherapy helps clients to explore anger, dependence, guilt, hopelessness, helplessness, object loss, interpersonal issues, and irrational beliefs. The goal is to reverse negative views of the future, improve self-image, and help clients gain competence and self-mastery.
When working with the family of a client with anorexia nervosa, which of the following issues must be addressed? A. Codependence B. Control issues C. Self-discipline D. Sexual identity
B Clients with anorexia often believe the only control they have is over their eating and weight; all other aspects of their life are controlled by their family. Codependence, self-discipline, and sexual identity are not pertinent issues to address with the family.
The most effective intervention for clients with delirium is which of the following? A. Giving detailed explanations B. Managing environmental stimuli C. Promoting rest with PRN medications D. Providing activities for distraction
B Clients with delirium become overstimulated easily; their ability to process environmental stimuli is impaired.
Which cluster of personality disorders includes people who appear dramatic, emotional, or erratic? A. Cluster A B. Cluster B C. Cluster C D. Cluster D
B Cluster B includes individuals who appear dramatic, emotional, or erratic. Cluster C includes clients who appear anxious or fearful, such as avoidant, dependent, and obsessive-compulsive. Cluster A includes individuals whose behavior appears odd or eccentric. There is currently no Cluster D in the DSM-IV-TR.
A visitor comes to see a suicidal patient. Upon entering the unit, the nurse notices that the visitor has brought the patient a can of their favorite soda. Which of the following actions should the nurse take at his time? A. Confiscate the soda can as a restricted item B. Pour the soda into a plastic cup C. Ask the visitor to place the soda can at the nurse's desk until they leave D. Ask the visitor not to bring outside items on the unit in the future
B For suicidal clients, staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings. The patient could access the soda can and commit self-harm.
The nurse is preparing a client with schizophrenia for discharge. The nurse asks the client, "How are you going to care for yourself at home?" The purpose of the nurse's question is to assess the client's... A. self concept. B. insight. C. judgment. D. social support system.
B Insight refers to the client's degree of self-awareness and realistic view of life. It can be severely impaired in schizophrenia. A client who lacks insight is likely to describe an unrealistic or inappropriate plan for self-care, so asking about self-care is a way of gauging the client's insight. Self-concept addresses core issues of personal identity, which are less likely to be revealed in a discussion about practical plans for self-care. Over time, some clients can learn about the illness, anticipate problems, and seek appropriate assistance as needed. Judgment refers to appropriate decision-making ability and is based on the ability to interpret the environment correctly. Judgment is usually assessed with reference to a particular dilemma or challenge, not a plan for self-care. Asking about the client's personal plans does not elicit information about who else may be available to support the client.
A patient is sitting alone, slouched, with eyes closed. The nurses approaches. Which statement is most likely to encourage the patient to talk? A."If you are sleepy, would you like me to help you back to your room?" B. "You look like you are deep in thought." C. "Is something wrong?" D. "Why are you sitting with your eyes closed?"
B Making observations—verbalizing what the nurse perceives. Sometimes clients cannot verbalize or make themselves understood. Or the client may not be ready to talk.
The nurse performs with of the following interventions to establish healthy eating patterns for a patient with anorexia? A. Leave the patient alone to relax during meals B.Offer liquid protein supplements if client is unable to complete meal. C. Observe the patient for 30 minutes after all meals. D.Weigh the patient weekly in the same clothing at the same time of day.
B Nursing interventions designed to establish nutritional eating patterns include sitting with the client during meals and snacks, offering liquid protein supplement if client is unable to complete meal, adhering to treatment program guidelines regarding restrictions, observing client following meals and snacks for 1 to 2 hours, weighing client daily in uniform clothing, and being alert for attempts to hide or discard food or inflate weight.
Which of the following is a term used to describe the occurrence of the eye rolling back in a locked position, which occurs with acute dystonia? A. Opisthotonus B. Oculogyric crisis C. Torticollis D. Pseudoparkinsonism
B Oculogyric crisis is the occurrence of the eye rolling back in a locked position, which occurs with acute dystonia.
Long-stay clients in an inpatient setting are people with severe and persistent mental illness who continue to require acute care services despite the current emphasis on decreased hospital stays. This population includes clients who were hospitalized before deinstitutionalization and remain hospitalized despite efforts at community placement. It also includes clients who have been hospitalized consistently for long periods despite efforts to minimize their hospital stays. Partial hospitalization is designed for patients transitioning to independent living. Residential treatment and clubhouse model provide supervised independent living. A. "I'll expect you in the dining room in 20 minutes." B. "It's time to put your dress on now." C. "Stay right there and I'll get your clothes for you." D. "Why don't you stay here and I'll get your tray for you."
B The client needs clear direction, with tasks broken into small steps, to begin to participate in her own self-care.
When working with a client with anorexia nervosa, which of the following nursing diagnoses is most difficult to resolve successfully? A. Imbalanced nutrition: less than body requirements B. Disturbed body image C. Deficient knowledge (nutritious eating patterns) D. Social isolation
B The client's dissatisfaction with body image is an enduring belief pattern that is firmly ingrained and, therefore, very difficult to change. Imbalanced nutrition: less than body requirements, deficient knowledge (nutritious eating patterns), and social isolation are nursing diagnoses that can be worked through with education and support more easily than the diagnosis of disturbed body image.
During the admission interview, the nurse asks the client what led to his hospitalization. The client responds, "They lied about me. They said I murdered my mother. You're the killers. You all killed my mother. She died before I was born." The best initial response by the nurse would be, A. "I just saw your mother. She's fine." B. "You're having very frightening thoughts." C."We'll put you in a private room until you're in better control." D."If your mother died before you were born, you wouldn't be here."
B The nurse is verbalizing the implied (that the client is frightened). Answers A, C, and D would not be in the initial response in this situation.
A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale? A. As soon as lunch is over, the client will calm down. B. Other clients need to be protected from the intrusive behavior. C.The client's behavior is not an imminent threat to anyone's physical safety. D. The client needs food and fluids in any way possible.
B The nurse must set limits on this intrusive behavior because other clients have the right to be protected. The client is in the manic phase; the client may not calm down after lunch. Answers C and D are incorrect rationale for the situation.
The nurse is teaching nutritional needs to the family of a patient with bulimia. The nurse should encourage the family to develop which of the following dietary patterns to assist the patient in recovering from bulimia? A. Provide the patient a diet of mainly vegetables and salads B. Encourage the entire family to engage in a balanced and regular dietary pattern C. Encourage autonomy by allowing the patient total control over food choices D. Insist that the patient complete all meals provided
B The nurse provides extensive teaching about basic nutritional needs and the effects of restrictive eating, dieting, and the binge and purge cycle. Clients need encouragement to set realistic goals for eating throughout the day. Eating only salads and vegetables during the day may set up clients for later binges as a result of too little dietary fat and carbohydrates. The patient with an eating disorder will not make healthy food choices independently. It is also not possible for family and friends to force the client to eat.
Which of the following clients would have an increased risk for delirium? A. Elderly woman with abdominal pain B. 3-year-old child with a temperature of 103.2 °F C. Middle-aged woman newly diagnosed with multiple sclerosis D. Young adult male with gastroenteritis and dehydration
B Young children with high fevers are at risk for delirium. Answers A, C, and D would not be the most likely candidates for increased risk for delirium.
The nurse is assessing a patient with bulimia nervosa. Which of the following symptoms would the nurse expect to find? (Select all that apply) A. Cold intolerance B. Normal weight for height C. Dental erosion D. Hypotension E. Metabolic alkalosis
B,C The weight of clients with bulimia usually is in the normal range, although some clients are overweight or underweight. Recurrent vomiting destroys tooth enamel, and incidence of dental caries and ragged or chipped teeth increases in these clients. Metabolic alkalosis often results from vomiting. Cold intolerance and hypotension are symptoms associated with emaciation seen in anorexia nervosa.
The nurse is educating a patient and family about strategies to minimize the side effects of antipsychotic drugs. Which of the following should be included in the plan? Select all that apply: A. Drink plenty of fruit juice B. Developing an exercise program is important C. Increase foods high in fiber D. Laxatives can be used as needed E. Use sunscreen when outdoors F. For missed doses, take double the dose at the next scheduled time.
B,C,E Drinking sugar-free fluids and eating sugar-free hard candy ease dry mouth. The client should avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. Methods to prevent or relieve constipation include exercising and increasing water and bulk-forming foods in the diet. Stool softeners are permissible, but the client should avoid laxatives. The use of sunscreen is recommended because photosensitivity can cause the client to sunburn easily. If the client forgets a dose of antipsychotic medication, he or she can take the missed dose if it is only 3 or 4 hours late. If the dose is more than 4 hours overdue or the next dose is due, the client can omit the forgotten dose.
The family of a young adult schizophrenic male asks how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for the following: (Select all that apply) A. Excessive sleeping B. Fatigue C. Irritability D. Increased inhibition E. Negativity
B,CE Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Early signs of relapse include impaired cause-and-effect reasoning, impaired information processing, poor nutrition, lack of sleep, lack of exercise, fatigue, poor social skills, social isolation, loneliness, interpersonal difficulties, lack of control, irritability, mood swings, ineffective medication management, low self-concept, looks and acts different, hopeless feelings, loss of motivation, anxiety and worry, disinhibition, increased negativity, neglecting appearance, and forgetfulness.
Which of the following terms is used to describe deterioration in language function A. Agnosia B. Apraxia C. Aphasia D. Executive functioning
C Aphasia is a deterioration of language function. Agnosia is the inability to recognize the name of objects. Apraxia is the impaired ability to execute motor functions despite intact motor abilities. Executive functioning is the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior.
A client with schizophrenia is reluctant to take his prescribed oral medication. The most therapeutic response by the nurse to this refusal is, A. "I can see that you're uncomfortable now, so we can wait until tomorrow." B. "If you refuse these pills, you'll have to get an injection." C. "What is it about the medicine that you don't like?" D. "You know you have to take this medicine for your own good.
C Asking the client why he doesn't like his medication explores the client's reason for refusal, which is the first step in resolving the issue. Waiting until tomorrow puts off the inevitable. Telling him it is for his own good is not the most therapeutic response in order to get the client to take his medication.
The nurse is assisting the patient with anorexia express feelings more openly. Which of the following is the most helpful response by the nurse to encourage expression of feelings? A. "Are you sad?" B. "You look anxious." C. "Tell me what you are feeling right now." D. "Tell me when you feel bad."
C Because clients with anorexia have problems with self-awareness, they often have difficulty identifying and expressing feelings. Therefore, they often express these feelings in terms of somatic complaints such as feeling fat or bloated. The nurse can help clients begin to recognize emotions by asking them to describe how they are feeling and allowing adequate time for response. The nurse should not ask, "Are you sad?" or "Are you anxious?" because a client may quickly agree rather than struggle for an answer. The nurse encourages the client to describe her or his feelings.
When assessing a client with narcissistic personality disorder, the nurse would expect the client to demonstrate which of the following? A. Genuine concern for others B. Mistrust of others C. Grandiose and superior self-concept D. Dependence on others for decision making
C Clients with narcissistic personality disorder believe themselves superior to others and expect to be treated as such.
A nurse is teaching a patient with borderline personality disorder to reshape thinking patters. Which of the following is an example of a cognitive restructuring technique that would be helpful for this patient? A. When negative thoughts begin, tell yourself "stop" B. Learn to look at situations realistically rather than assuming the worst C. Recognize negative thoughts and replace them with positive ones D. Express needs using "I" statements
C Cognitive restructuring is a technique useful in changing patterns of thinking by helping clients to recognize negative thought and feelings and to replace them with positive patterns of thinking. Thought stopping is a technique to alter the process of negative or self-critical thought patterns .When the thoughts begin, the client may actually say "Stop!" in a loud voice to stop the negative thoughts. Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. Assertive communication involves using "I" statements.
The nurse can distinguish delirium from dementia by knowing which of the following?
C Delirium has a sudden onset and the underlying cause is treatable; by contrast, dementia has a gradual onset and is progressive rather than treatable.
The nurse is teaching a 70-year-old man about his depression. Which of the following statements by the client would indicate that teaching has been effective? A. "All old people get depressed at times." B. "I'm glad I'll feel better in 2 or 3 days." C. "I never knew depression could just happen for no specific reason." D. "When I reduce the stress in my life, the depression will go away."
C Depression can be endogenous, with no external cause or event. Clients must understand that depression is an illness, not a lack of willpower or motivation. Major depression typically involves 2 or more weeks of a sad mood or lack of interest in life activities with at least four other symptoms of depression.
The nurse is planning care for a patient with major depression. Which of the following is an appropriate expected outcome? A. Patient will avoid causing harm to others B. Patient will be free from stress C. Patient will express emotions outwardly D. Patient will not experience agitation
C Expected outcomes for the depressed client include: The client will • Be free from self-inflicted harm • Engage in reality-based interactions • Be oriented to person, place, and time • Express anger or hostility outwardly in a safe manner, e.g., talking with staff members. Avoiding agitation and harm to others are outcomes more appropriate for a patient with mania. It is unrealistic to be completely free from stress.
A patient who has continuously experienced severe symptoms of schizoaffective disorder for the past 17 years is experiencing an acute psychotic episode. Which level of care is most appropriate for this patient at this time? A. Partial hospitalization B. Residential treatment C. Inpatient hospital treatment D. Clubhouse
C Long-stay clients in an inpatient setting are people with severe and persistent mental illness who continue to require acute care services despite the current emphasis on decreased hospital stays. This population includes clients who were hospitalized before deinstitutionalization and remain hospitalized despite efforts at community placement. It also includes clients who have been hospitalized consistently for long periods despite efforts to minimize their hospital stays. Partial hospitalization is designed for patients transitioning to independent living. Residential treatment and clubhouse model provide supervised independent living.
Which of the following interventions would be appropriate for a client with anorexia nervosa? A. Allowing the client to eat whenever she feels hungry B. Insisting that the client sit in the dining room until all food is eaten C. Having the client in view of staff for 90 minutes after each meal D. Permitting the client to eat any food she chooses, as long as she is eating
C Many clients with anorexia also have purging behavior; even those who have not purged previously may begin to do so when they are unable to restrict their eating. Choices A, B, and D do not promote healthy eating behaviors.
A patient with biploar disorder takes lithium 300mg three times daily. The nurse evaluates the dose is appropriate when the patient reports: A. Feeling sleepy and less energetic B. Weight gain of 7 pounds in the last 6 months C. Minimal mood swings D. Increased feelings of self-worth
C Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Weight gain is a common side effect, and fatigue and lethargy may indicate mild toxicity. Inflated self-worth is a target symptom of bipolar disorder which should diminish with effective treatment.
A patient is seen for frequent exacerbation of schizophrenia due to non-adherence to medication regime. The nurse should assess for which of the following common contributors to non-adherence: A.The patient is symptom-free and therefore does not need to adhere to the medication regime B.The patient cannot clearly see the instructions written on the prescription bottle C.The patient dislikes the weight gain associated with antipsychotic therapy D.The patient sells the antipsychotics to addicts in the neighborhood
C Patients with schizophrenia are less likely to exercise or eat low-fat nutritionally balanced diets; this pattern decreases the likelihood that they can minimize potential weight gain or lose excess weight. Antipsychotics should be taken regularly and not omitted when free of symptoms. Antipsychotics do not adversely affect vision, nor do they have addictive potential.
Discharge planning from inpatient care for people with severe mental illness needs to address which of the following to be effective? A. Locating an outpatient therapist B. Finding a job for the client C. Finding housing and transportation D. Improving family support
C People are able to remain in the community for longer periods of time when discharge planning addresses environmental supports, housing, transportation, and access to community support services.
The nurse has completed health teaching about dietary restrictions for a client taking a monoamine oxidase inhibitor. The nurse will know that teaching has been effective by which of the following client statements? A. "I'm glad I can eat pizza since it's my favorite food." B. "I must follow this diet or I will have severe vomiting." C. "It will be difficult for me to avoid pepperoni." D."None of the foods that are restricted are part of a regular daily diet."
C Pepperoni is one of the foods containing tyramine, so it must be avoided. Particular concern to this client is the potential life-threatening hypertensive crisis if the client ingests food that contains tyramine. Answers A, B, and D are inappropriate statements toward effective teaching for the client receiving a monoamine oxidase inhibitor.
In report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. The best response by the nurse would be, A. "Do you think you could sit still for a few minutes so we can talk?" B. "How are you ever going to get any rest if you keep that music on?" C. "Let's go to the conference room and talk for a while." D. "Turn the radio down so we can hear ourselves talk."
C Redirecting the client to a quieter, smaller room will decrease external stimuli and promote calmness so the client will eventually rest and sleep.
Which of the following interventions should the nurse include in a plan of care for a client with histrionic personality disorder? A. Accept the client's behavior B. Assist the client to eliminate passive behavior C. Set limits on attention-seeking behavior D. Try to meet the client's needs for attention
C Setting limits on attention-seeking behavior, and discussing alternatives for appropriate behavior, will promote growth. Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Acceptance of the behavior will cause the behavior to be intensified. These clients are not passive in nature. Answer D is an inappropriate intervention since these clients are already seeking attention.
A client who is taking paroxetine (Paxil) reports to the nurse that he has been nauseated since beginning the medication. Which of the following actions is indicated initially? A.Instruct the client to stop the medication for a few days to see if the nausea goes away. B. Reassure the client that this is an expected side effect that will improve with time. C. Suggest that the client take the medication with food. D. Tell the client to contact the physician for a change in medication.
C Taking Paxil with food usually eliminates nausea. There is a delayed therapeutic response to antidepressants. The client should not stop taking the drug. Answers B and C are appropriate but are not done initially.
One week after beginning therapy with thiothixene (Navane), the client demonstrates muscle rigidity, a temperature of 103 °F, an elevated serum creatinine phosphokinase level, stupor, and incontinence. The nurse should notify the physician because these symptoms are indicative of A. Acute dystonic reaction B. Extrapyramidal side effects C. Neuroleptic malignant syndrome D. Tardive dyskinesia
C The client demonstrates all the classic signs of neuroleptic malignant syndrome. Dystonia involves acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. Extrapyramidal side effects are reversible movement disorders induced by antipsychotic or neuroleptic medication. Tardive dyskinesia is a late-onset, irreversible neurologic side effect of antipsychotic medications characterized by abnormal, involuntary movements, such as blinking, chewing, and grimacing.
A patient with antisocial personality disorder is begging to use the phone to call his wife, even though it is against the unit rules. The patient begs, "It is just this once and she will be so hurt if I don't call her." An appropriate response by the nurse would be: A. "Only to help your wife, you can call this time." B. "I will get in trouble with my supervisor if I let you call." C. "You may not use the phone to call your wife." D."You cannot call because you need to focus on your recovery while you are here, not your wife."
C The client may attempt to bend the rules "just this once" with numerous excuses and justifications. The nurse's refusal to be manipulated or charmed will help decrease manipulative behavior. Avoid any discussion about why requirements exist. State the requirement in a matter-of-fact manner. Avoid arguing with the client.
A schizophrenic patient having a conversation with the nurse suddenly stops talking in the middle of a sentence. The patient is experiencing which type of thought disruption A. Thought withdrawal B. Thought insertion C. Thought blocking D. Thought broadcasting
C The nurse can assess thought content by evaluating what the client actually says. For example, clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking). They also may state that they believe others can hear their thoughts (thought broadcasting), that others are taking their thoughts (thought withdrawal), or that others are placing thoughts in their mind against their will (thought insertion).
The daughter of a woman with dementia asks the nurse if the patient will ever be able to live independently again. The most appropriate response by the nurse would be: A. "You sound like you aren't ready for her to be dependent on caregivers." B."Her confusion is a temporary complication of her physical illness and should subside when the illness gets better." C."Symptoms of dementia gradually get worse. Unfortunately she will not be independent again." D. "With early treatment mild dementia can be reversed. It may be possible"
C The prognosis for dementia involves progressive deterioration of physical and mental abilities until death. Typically, in the later stages, clients have minimal cognitive and motor function, are totally dependent on caregivers, and are unaware of their surroundings or people in the environment. They may be totally uncommunicative or make unintelligible sounds or attempts to verbalize. Delirium secondary to physical illness will subside with physical recovery.
The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which of the following responses by the nurse is best in this situation? A. "It would be best if you just took your shower now." B. "You seem anxious and upset." C."You have plenty of time to shower before it's time to go home." D. "Why are you thinking you're going home?"
C This is an example of going along with, rather than correcting, the client's misperception so that she can get on with her daily activities and not focus on being upset about not going home. Answers A, B, and D are not the best responses in this situation.
A client with bipolar disorder has been taking lithium, and today his serum blood level is 2.0 mEq/L. What effects would the nurse expect to see? A. Constipation and postural hypotension B. Fever, muscle rigidity, and disorientation C. Nausea, diarrhea, and confusion D. None; the serum level is in therapeutic range
CThe client would show signs of toxicity with a lithium level of 2.0 mEq/L. Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. The serum level is not in therapeutic range.
A patient has frequent suspicious reactions to peers on the unit. As a result, others do not include him in conversation and activities. The nurse would report that the patient is displaying behaviors associated with which cluster of personality disorders? A. Cluster A B. Cluster B C. Cluster C D. Cluster D
Cluster A includes people whose behavior appears odd or eccentric and includes paranoid, schizoid, and schizotypal personality disorders. Cluster B includes people who appear dramatic, emotional, or erratic and includes antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C includes people who appear anxious or fearful and includes avoidant, dependent and obsessive-compulsive personality disorders.
The staff meets weekly to discuss the care of a patient with antisocial personality disorder. Which of the following is the main reason why the periodic team meetings are important when caring for the patient? A.The team needs to consider updating treatment recommendations as the patient improves B. Rotating team members need to be apprised of the care planned for the patient C. Staff frustrations in caring for the patient need to be processed D. Team consistency is important to prevent manipulation by the patient
D Be consistent and firm with the care plan. Do not make independent changes in rules or consequences. Any change should be made by the staff as a group and conveyed to all staff members working with this client. Consistency is essential. If the client can find just one person to make independent changes, any plan will become ineffective. Patient changes can be expected to be gradual and minimal. While all team members need to be apprised of the treatment plan, the main reason is to avoid inconsistencies. Staff's frustrations must be dealt with appropriately, but the primary focus for all treatment planning should be centered on meeting the patient's needs.
he staff meets weekly to discuss the care of a patient with antisocial personality disorder. Which of the following is the main reason why the periodic team meetings are important when caring for the patient? A.The team needs to consider updating treatment recommendations as the patient improves B.Rotating team members need to be apprised of the care planned for the patient C. Staff frustrations in caring for the patient need to be processed D.Team consistency is important to prevent manipulation by the patient
D Be consistent and firm with the care plan. Do not make independent changes in rules or consequences. Any change should be made by the staff as a group and conveyed to all staff members working with this client. Consistency is essential. If the client can find just one person to make independent changes, any plan will become ineffective. Patient changes can be expected to be gradual and minimal. While all team members need to be apprised of the treatment plan, the main reason is to avoid inconsistencies. Staff's frustrations must be dealt with appropriately, but the primary focus for all treatment planning should be centered on meeting the patient's needs.
A manic patient is threatening others on the unit. The initial nursing action in response to this behavior includes which of the following? A. Administration of a prn sedative B. Insisting the patient take a "time out" in his room C. Clearing other patients out of the area D. Set limits on aggressive and intimidating behavior
D Because of the safety risks that clients in the manic phase take, safety plays a primary role in care, followed by issues related to self-esteem and socialization. It is necessary to set limits when they cannot set limits on themselves. Giving the client the opportunity to exercise self-control is most therapeutic. If the client cannot control behavior then more restrictive measures can be taken, such as room restriction or sedation. Clearing the area is not necessary during limit setting, and may cause excessive panic on the part of other patients.
Which of the following would not be included as a symptom of drug-induced Parkinsonism? A. Stooped posture B. Cogwheel rigidity C. Drooling D. Tachycardia
D Bradycardia, a stooped posture, cogwheel rigidity, and drooling are all symptoms of pseudoparkinsonism.
A client is admitted for a drug overdose with a central nervous system (CNS) depressant. The priority nursing action when planning care for this client would be to A. Check the client's belongings for additional drugs B. Pad the side rails of the bed because seizures are likely C. Prepare a dose of ipecac, an emetic D. Monitor respiratory function
D CNS depressants depress respiratory functioning. Choices A, B, C would not be priority nursing actions in this situation.
he daughter of a patient with dementia has been the primary caregiver for 5 months. The daughter expresses to the nurse, "At times it is so overwhelming! I feel I do not have a life anymore!" Which of the following is the most helpful response by the nurse? A. "Are you saying you don't want to care for your mother anymore?" B. "I know it is really hard. It takes a lot of work and you are doing such a good job." C."Your mother really appreciates what you do for her. You are the best one to care for her." D."Here is the number of a caregiver's support group. How do you think you would feel talking with others in the same situation?"
D Caregivers need outlets for dealing with their own feelings. Support groups can help them to express frustration, sadness, anger, guilt, or ambivalence; all these feelings are common. Attending a support group regularly also means that caregivers have time with people who understand the many demands of caring for a family member with dementia. The client's physician can provide information about support groups, and the local chapter of the National Alzheimer's Disease Association is listed in the phone book. Area hospitals and public health agencies also can help caregivers to locate community resources. The nurse should understand that the caregiver is asking for help when expressing frustration. The nurse should not dismiss the caregiver's feelings or in any way induce additional guilt.
The nurse is working with a client with antisocial personality disorder. This client's desire to do everything for himself is based on which of the following? A. Belief in his own self-worth B. Inability to delay gratification C. Rewards for competitive behavior D. Sense of mistrust of others
D Clients believe others are just like them, that is, ready to exploit and use others for their own gain. These clients are devoid of personal emotions and actually the self is quite shallow and empty. These clients view relationships as serving their needs and pursue others only for personal gain. There is no competition because these clients believe they are only taking care of themselves because no one else will.
A nursing student is elected leader of a group project because she always stays up half the night making sure every detail of an assignment is perfect. However, the student is never fully satisfied with her wok and is making changes up until the deadline. The nursing student may be showing signs of which personality disorder? A. Paranoid B. Borderline C. Narcissistic D. Obsessive-compulsive
D Cluster C includes people who appear anxious or fearful and includes avoidant, dependent and obsessive-compulsive personality disorders. Cluster A includes people whose behavior appears odd or eccentric and includes paranoid, schizoid, and schizotypal personality disorders. Cluster B includes people who appear dramatic, emotional, or erratic and includes antisocial, borderline, histrionic, and narcissistic personality disorders.
A nurse has been assigned a newly admitted client. The client's report notes that the client is demonstrating grandiosity. Which client statement is most consistent with this symptom? A. "I can't understand where all the money in our family goes." B. "I can understand why my wife is upset that I overspend." C. "I can't do anything anymore." D. "I'm the world's most astute financier."
D Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that he or she is famous or capable of great feats. Examples: The client may claim to be engaged to a famous movie star or related to a public figure. An individual who is demonstrating grandiosity has an exaggerated view of his or her abilities. The other options are more moderate statements and lack the element of exaggeration.
The nurse teaches an antisocial patient to take a time out in his room when challenged by another person instigating an argument. The main reason for the time out is which of the following? A. It allows time for the instigator to leave the area B.It allows adequate space between the patient and the instigating individual C.It prevents the patient from experiencing negative consequences of behavior D.It allows an opportunity for the patient to regain control of emotions
D Managing emotions, especially anger and frustration, can be a major problem. Taking a time-out or leaving the area and going to a neutral place to regain internal control are often helpful strategies. Time-outs help clients to avoid impulsive reactions and angry outbursts in emotionally charged situations, regain control of emotions, and engage in constructive problem-solving.
A psychiatric nurse is planning activities aimed at secondary prevention of mental illness. Which activity would be most appropriate to develop? A. Self-esteem building with a local after-school program B. Social skills training for chronic schizophrenics C. Parenthood classes at a local community center D. Depression screening in an assisted living facility
D Nurses work to provide mental health prevention services to reduce risks to the mental health of persons, families, and communities. Examples include primary prevention, such as stress management education; secondary prevention, such as early identification of potential mental health problems; and tertiary prevention, such as monitoring and coordinating rehabilitation services for the mentally ill.
A patient has a history of suicidal ideation. The nurse understands that the patient is at highest risk for self-harm at which of the following times? A. Immediately after a family visit B.On the anniversary of significant life events in the patient's life C. During the first few days after admission D.Approximately 2 weeks after starting antidepressant medication
D Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication.
The priority of inpatient care for people with severe mental illness is A. Family issues B. Insight into illness C. Social skills D. Symptom management
D Rapid assessment, stabilization of symptoms, and discharge planning are the focus of inpatient care today. Family issues, insight into illness, and social skills would not be priorities of care for clients with severe mental illness.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority? A. Hopelessness related to recent divorce B. Ineffective coping related to inadequate stress management C. Spiritual distress related to conflicting thoughts about suicide and sin D. Risk for suicide related to highly lethal plan
D Safety is the priority. The overall goals for the client who is suicidal is to first keep the client safe and later to help him or her to develop new coping skills that do not involve self-harm. Answers A, B, and C would not be the priority diagnosis for this client.
A 50-year-old client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. The nurse observes that the client's behavior includes repetitive movements of the mouth and tongue, facial grimacing, and rocking back and forth. The nurse recognizes these behaviors as indicative of A. Extrapyramidal side effects B. Loss of voluntary muscle control C. Posturing D. Tardive dyskinesia
D The client's behaviors are classic signs of tardive dyskinesia. Extrapyramidal side effects are reversible movement disorders induced by antipsychotic or neuroleptic medication. The client's behavior is not a loss of voluntary control or posturing.
The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which of the following interventions should the nurse implement first? A.Administer an antianxiety drug such as lorazepam (Ativan) at these times. B.Explain the unit routine and the reasons for increased activity to the client. C. Keep unit activity to a minimum. D. Move the client to a quieter area during these times.
D The nurse must alter the environment because the client will not learn new coping skills for frustrating or overly stimulating situations. Administering an antianxiety agent or explaining the routine of the unit and reasons for increased activity to the client may be done but would not be the initial intervention. The unit activity does not need to be kept to a minimum.
A patient voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The patient approaches the nurse and states, "I'm going to take walk outside. I'll be back in about 10 minutes." The most appropriate nursing action is which of the following? A. Further assess the patient's motives for wanting to walk B. Give the patient permission to go on a walk on the grounds C. Tell the patient the walk is not allowed and restrict him to the unit D. Designate a staff member to accompany the patient on the walk
D The nurse teaches clients to request assistance for activities such as getting out of bed or going to the bathroom. If clients cannot request assistance, they require close supervision to prevent them from attempting activities they cannot perform safely alone. The nurse responds promptly to calls from clients for assistance and checks clients at frequent intervals.
Realistic outcomes for the care of a person with a personality disorder include A. Outcomes which focus on satisfaction with daily life B. Outcomes which focus on patient's perception of others C. Outcomes which focus on increased patient insight D. Outcomes which focus on change in behavior
D The treatment focus often is behavioral change. Although treatment is unlikely to affect the client's insight or view of the world and others, it is possible to make changes in behavio
A patient states, "I feel fine. It's a good day." The nurse notes the patient looking away, and a decreasing pitch in his voice while speaking. Which of the following is the most therapeutic response by the nurse? A. "I'm glad you are feeling good today." B. "I'm not sure I believe you." C. "Tell me what is good about today." D. "You say you feel fine, but you don't really sound fine."
D To ensure the accuracy of the patient's messages, the nurse identifies the nonverbal communication and checks its congruency with the content. An example is "Mr. Jones, you said everything is fine today, yet you frowned as you spoke. I sense that everything is not really fine" (verbalizing the implied).
All of the following nursing diagnoses are appropriate for the care of a patient with anorexia. List the diagnoses in order of priority. A. Activity Intolerance B. Ineffective Coping C. Chronic Low Self-esteem D. Imbalanced Nutrition: Less than Body Requirements
D,A,B,C Nursing diagnoses for clients with eating disorders include Imbalanced Nutrition: Less Than/More than Body Requirements, Activity Intolerance, Ineffective Coping, and Chronic Low Self-esteem. When prioritizing nursing diagnoses, physical needs must be met before psychosocial needs (apply Maslow's hierarchy of needs). Of the physical needs, nutritional imbalances pose a more acute threat than decreased activity levels. When addressing psychosocial needs, improving coping skills will eventually lead to rise in self-esteem.
The nurse encourages the patient with dementia to meet nutritional needs. Which of the following is the best approach to assist in meeting adequate dietary intake? A. Sit with the patient as long as necessary to complete the meal B. Provide entertainment during meals such as television or music C. Avoid between-meal snacks to encourage appetite D. Serve meals in small, bite-size pieces
DClients may eat poorly because of limited appetite or distraction at mealtimes. The nurse addresses this problem by providing foods clients like, sitting with clients at meals to provide cues to continue eating, having nutritious snacks available whenever clients are hungry, and minimizing noise and undue distraction at mealtimes. Clients who have difficulty manipulating utensils may be unable to cut meat or other foods into bite-sized pieces. The food should be cut up when it is prepared, not in front of clients, to deflect attention from their inability to do so. Food that can be eaten without utensils, or finger foods such as sandwiches and fresh fruit, may be best.
The nurse uses a variety of therapeutic communication skills when working with patients. Which of the following are therapeutic goals that can be accomplished through the use of therapeutic communication skills? A. Inform the patient of priority problems B. Assess the patient's perception of a problem C. Assist the patient to control emotions D. Provide the patient with a plan of action
b Therapeutic communication can help nurses to accomplish many goals including identifying the most important concern to the client at that moment, assessing the client's perception of the problem, facilitating the client's expression of emotions, and guiding the client toward identifying a plan of action.
At 1 a.m., the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. Which response by the nurse would be the most therapeutic? A. "Go to the day room and wait while I call your psychiatrist." B. "Don't be unreasonable. I can't call the psychiatrist at this time of night." C."I can't call the psychiatrist now, but you and I can talk about your request for a pass." D."You must really be upset to want a pass immediately; I'll give you a PRN medication."
c This response states a limit on an unreasonable request while providing the opportunity to discuss the request. Answers A, B, and D are not therapeutic.
