Psych practice questions schzio, bipolar, depression, NCD

A client has been diagnosed with major depression. The psychiatrist prescribes imipramine (Tofranil). Which of the following medication information should the nurse include in discharge teaching? Select all that apply.

1) "The medication may cause dry mouth." 3) "The medication should not be discontinued abruptly." 4) "The medication may cause photosensitivity." 5) "The medication may cause nausea."

A client diagnosed with major depression is being discharged from the hospital with a prescription for fluoxetine (Prozac). The nurse's discharge teaching should include which of the following? Select all that apply.

1) "It may take a few weeks before you begin to feel better; however, continue taking Prozac as prescribed." 2) "Make sure that you follow up with scheduled outpatient psychotherapy." 3) "If significant mood elevation is noted, your psychiatrist may discontinue this medication within 6 months to a year."

A client being treated for depression asks the nurse what causes this illness. Which response by the nurse is the most accurate, evidence-based statement?

1) "The etiology of depression is unclear. Evidence supports there may be several different causative factors."

Lamont has been scheduled for electroconvulsive therapy (ECT) and asks the nurse, "Is it true what I heard, that ECT causes brain damage?" Which of these would be the most appropriate, evidence-based response by the nurse?

3) "There is no evidence that ECT causes permanent changes in brain structure or function."

Hannah is being evaluated for postpartum depression after she reported to her family physician that she just doesn't think she can take care of her baby. She expresses fear that God will take her children from her for being a bad mother. Which of the following is the highest priority for the nurse to assess during the initial interview?

3) Risks for suicide and/or infanticide.

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

ANS: putting a blanket around the patient and walking with the patient to a quiet room. Patients must be protected from the embarrassing consequences of their poor judgment whenever possible.

A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge?

The client will identify events that increase anxiety and illicit hallucinations. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.

Shelly is a patient on the inpatient psychiatric unit and was diagnosed with major depressive disorder. She is staying in her room and sleeping most of the day. Which of the following approaches by the nurse would best facilitate getting Shelly involved in the occupational therapy group on the unit?

"Occupational therapy is starting in 30 minutes; I'll help you get ready."

When teaching about the tricyclic group of antidepressant medications, which information should the nurse include?

2) The full therapeutic potential of tricyclics may not be reached for 4 weeks.

Which of the following are likely traits of a client with Schizophrenia? A. Flat affect B. Loose associations C. Delusions D. Paranoid E. Lack of guilt or remorse

A, B, C, D Schizophrenic clients will usually display social withdrawal, flat affect, depersonalization, suspiciousness, delusions, hallucinations, and have loose associations. A lack of guilt or remorse is more descriptive of a antisocial personality disorder

A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply?

A. "Your child has a chemical imbalance of the brain which leads to altered thoughts." The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses.

A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which intervention should the nurse use first?

A. Ask the client about any previous problems with psychotropic medications. The nurse needs to clarify the client's previous experience with psychotropic medication in order to understand the meaning of the client's statement.

A patient with catatonic schizophrenia is in the hospital on the mental health unit. The patient has not moved for 3 days. Which of the following nursing interventions best demonstrates that the nurse is upholding the patients safety in this situation? A. Perform range of motion exercises and apply sequential compression devices B. Administer methylphenidate to control behavior C. Start an IV to administer a bolus of normal saline solution D. Place the patient in seclusion until the catatonia has resolved

A. Perform range of motion exercises and apply sequential compression devices

A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is: A. highly important or famous. B. being persecuted. C. connected to events unrelated to oneself. D. responsible for the evil in the world.

A. highly important or famous.

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

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

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective?

ANS: A "Converses with few interruptions; clothing matches; participates in activities." The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities.

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

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

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

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

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

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

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

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

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

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

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

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

Which of the following client behaviors documented in Gio's chart would validate the nursing diagnosis of Risk for other-directed violence?

B. Frequent angry outburst noted toward peers and staff

Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, "Get out of here right now! The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond? A. "Why do you think there is a bomb in the elevator?" B. "That is the same thing you said in yesterday's session." C. "I know you think there are bombs in the elevator, but there aren't." D. "If you have something to say, you must do it according to our group rules."

C. "I know you think there are bombs in the elevator, but there aren't."

During an assessment of a patient taking chlorpromazine, a first-generation antipsychotic, the provider notes a slow shuffling gait, rigid facial expression, and fine tremors. The provider recognizes this as which of the following? A. Acute dystonia B. Tardive dyskinesia C. Parkinsonism D. Akathisia

C. Parkinsonism

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: A. a delusion. B. flight of ideas. C. ideas of reference. D. a hallucination.

C. ideas of reference.

A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing?

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

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?

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

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?

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

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia?

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

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist?

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

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). A nurse assesses the results of which laboratory study to monitor for adverse effect related to this medication? A. White blood cell. B. Platelet count. C. Liver function studies. D. Random blood sugar.

A. White blood cell. Agranulocytosis my experience by the client taking clozapine which can be monitored by evaluating the white blood cell count.

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

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

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

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

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

ANS: C Broiled chicken breast on a roll, an ear of corn, and an apple These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement?

The nurse should describe the client's statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client.

The nurse is conducting an assessment for Leroy, a 65-year-old man who presented at the health clinic with complaints of depression. He lists several medications he has been taking. Of the following medications on his list, which are known to produce a depressive syndrome? Select all that apply.

1) Prednisone 2) Cimetidine Tagamet 3) Ampicillin 4) Ibuprofen

A client has a history of major depressive disorder (MDD). Police escort the client to the ED after finding the client nude at an ATM, screaming for money to pay off credit card debt. What would make the ED psychiatrist question the client's prior diagnosis?

1) The client is experiencing symptoms of mania.

Dementia unlike delirium is characterized by: A. Slurred speech B. Insidious onset C. Clouding of consciousness D. Sensory perceptual change

B. Insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances. A,C and D are all characteristics of delirium.

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?

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

The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by drawing up how many milliliters in the syringe? A. 0.3 B. 0.4 C. 0.5 D. 0.6

C. 0.5

Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of? A. Flight of ideas B. Associative looseness C. Confabulation D. Concretism

C. Confabulation

A patient with schizoaffective disorder has been admitted to the inpatient mental health center of the hospital. The patient tells the nurse that he hears voices telling him to leave the hospital. Which response from the nurse is best? A. I do not hear anything, but you have to stay in the hospital right now. B. Why do not we go to the game room and see what is happening there today? C. I do not hear anything, but I can see how you may feel worried about being in the hospital right now. D. You know that those voices aren't real, do you not?

C. I do not hear anything, but I can see how you may feel worried about being in the hospital right now. Some patients with mental health issues may have auditory hallucinations by hearing voices. When a patient has hallucinations, the nurse should not play into the situation, but she should also not deny that it is happening to the patient. The nurse must instead provide support and help the patient if he is having other feelings of anxiety or fear in addition to the hallucinations.

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

arrange for one-on-one supervision. A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure.

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse?

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

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms?

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

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom?

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

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking?

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

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to:

have someone bring the patient to the clinic immediately. The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person.

A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is: A. Being Killed B. Highly famous and important C. Responsible for evil world D. Connected to client unrelated to oneself

B. Highly famous and important

Susan is being seen in the emergency department. Her sister brought her in with concern that Susan is depressed and might be suicidal. Which of the following questions are priorities for the nurse to ask when assessing for suicide risk? Select all that apply.

2) "Are you having thoughts of hurting or killing yourself?" 3) "When you have these thoughts, do you have a plan in mind?" 5) "Are you currently using any drugs or alcohol?"

Janice is diagnosed with major depressive disorder and is beginning to participate in a cognitive therapy group. As the nurse is orienting Janice to the group, which of the following statements about cognitive therapy are accurate? Select all that apply.

2) Cognitive distortions, such as negative expectations about oneself, serve as the basis for depression. 3) Cognitive therapy focuses on altering mood by changing the way one thinks. 4) Cognitive distortions arise out of a defect in cognitive development.

Emily has been receiving treatment for major depressive disorder over several weeks. She is taking an antidepressant and attending cognitive behavioral therapy group once a week. When the nurse evaluates her progress in treatment, which of the following are indications that the depression is improving? Select all that apply.

2) Emily is expressing hope that she can return to her university classes soon and continue her education. 3) Emily demonstrates ability to make decisions concerning her own self-care. 4) Emily reports that suicide ideas have subsided. 5) Emily is engaging in activities that she enjoys.

Chloe is suffering from depression and not responding to antidepressant treatment. She asks the nurse to tell her more about transcranial magnetic stimulation (TMS). Which of the following responses is accurate with regard to this treatment modality?

2) One study concluded that electroconvulsive therapy was more effective than TMS for short-term treatment of depression.

The physician orders fluoxetine (Prozac) for a client diagnosed with depression. Which information is true about this medication?

2) The therapeutic effect of Prozac occurs 2 to 4 weeks after treatment is begun

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic? A. "That must be frightening to you. Can you tell me how you feel about it?" B. "There are no people living on Mars." C. "What do you mean when you say they're going to invade the earth?" D. "I know you believe the earth is going to be invaded, but I don't believe that."

A. "That must be frightening to you. Can you tell me how you feel about it?"

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

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

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

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

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment?

Attending psycho education sessions During the continuation phase of treatment for bipolar disorder, After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnosis

Chronic low self-esteem and powerlessness are interwoven in the patient's statements.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior?

Consider the need to check the lithium level. The patient may not be swallowing medications. The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" the medication.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely?

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

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

Restlessness and muscle rigidity Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response.

"Taking the medication every day helps reduce the risk of a relapse." Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

Cliff has been attending group counseling for depression and has been expressing more hopelessness in the last few days. When the nurse provides the group with a homework assignment to be completed and returned to the group the next day, Cliff responds "I don't need to bother." Which of these responses by the nurse is most appropriate?

1) "Are you having suicidal thoughts?" Hopelessness is a risk factor for suicide, and the client's statement may be a veiled suicide threat, so it is most important to assess for suicide risk in response.

A client is being treated with sertraline (Zoloft) for major depression. The client tells the nurse, "I've been taking this drug for only a week, but I'm sleeping better and my appetite has improved." Which is the most appropriate response by the nurse?

4) "The initiation of Zoloft therapy can improve insomnia and appetite within 1 week." The onset of action for Zoloft is 1 to 3 weeks. It is possible that the client is beginning to experience symptom relief from the therapeutic effect of Zoloft.

Tara experienced the death of a parent 2 years ago. She has not been able to work since the death, cannot look at any of the parent's belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes Tara's problem?

4) Grieving, complicated, R/T parent's death.

Bill is a 70-year-old man who is diagnosed with major depressive disorder. He is married and has two adult children who are alcoholics. He currently lives in a rural neighborhood and works part-time at a convenience mart. Which of these demographics is a risk factor for suicide?

70-year-old male Suicide is highest among persons over 50, and men are at higher risk than females.

The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? Select all that apply. A. Restating B. Listening C. Asking the patient "Why?" D. Maintaining neutral responses E. Providing acknowledgment and feedback F. Giving advice and approval or disapproval

A, B, D, and E. Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing

Mr. Lim who is diagnosed with moderate dementia has frequent catastrophic reactions during shower time. Which of the following interventions should be implemented in the plan of care? Select all that apply. A. Assign consistent staff members to assist the client. B. Accomplish the task quickly, with several staff members assisting. C. Schedule the client's shower at the same time of day. D. Sedate the client 30 minutes prior to showering. E. Tell the client to remain calm while showering. F. Use a calm, supportive, quiet manner when assisting the client.

A, C, F Maintaining a consistent routine with the same staff members will help decrease the client's anxiety that occurs whenever changes are made. A calm, quiet manner will be reassuring to the client, also helping to minimize anxiety.

The nurse would expect a client with early Alzheimer's disease to have problems with: A. Balancing a checkbook. B. Self-care measures. C. Relating to family members. D. Remembering his own name

A. Balancing a checkbook. In the early stage of Alzheimer's disease, complex tasks (such as balancing a checkbook) would be the first cognitive deficit to occur.

A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take INITIALLY? A. Contact the patient's health care provider (HCP). B. Call the patient's family to arrange for transportations. C. Attempt to persuade the patient to stay for only a few more days. D. Tell the patient that leaving would likely result in an involuntary commitment.

A. Contact the patient's health care provider (HCP). In general, patients seek, voluntary admission. Voluntary patients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The best nursing action is to contact the HCP, who has the authority to discuss discharge with the patient.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction? A. Dystonia B. Akinesia C. Akathisia D. Tardive dyskinesia

A. Dystonia

Nurse Dorothy is evaluating care of a client with schizophrenia; the nurse should keep which point in mind?

A. Frequent reassessment is needed and is based on the client's response to treatment.

Nurse Monette recognizes that the focus of Milieu therapy is to: A. Manipulate the environment to bring about positive changes in behavior B. Allow the client's freedom to determine whether or not they will be involved in activities C. Role play life events to meet individual needs D. Use natural remedies rather than drugs to control behavior

A. Manipulate the environment to bring about positive changes in behavior

When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others. B. Assist in completing an application for admission. C. Supply the patient with written information about their mental illness. D. Provide an opportunity for the family to discuss why they felt the admission was needed.

A. Monitor closely for harm to self or others. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the patient's willingness to consent to the hospitalization.

A client has come into the emergency room complaining about being followed and that people are trying to kill them. The nurse reviews the clients medications and notes the client is likely to have schizophrenia based on which medication? A. Olanzapine B. Omeprazole C. Oxycodone D. Oxytocin

A. Olanzapine

A psychiatric and mental health nurse is working with a family who is undergoing group therapy. Which action from the nurse best demonstrates the view of the family as a unit? A. Providing health education to all members of the family B. Asking about the health needs of individual family members C. Organizing a schedule of meeting with each family member involved D. Arranging for another therapist to meet with some of the family members at different times

A. Providing health education to all members of the family When working together as a unit, the family may seek therapy or group counseling to overcome a challenging situation. The nurse may give advice and support to all members of the family involved to help them work together. When the nurse must provide health education and instruction, she may teach everyone in the family so that all members understand.

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

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

A nurse is working with a client who has schizophrenia, paranoid type. Which of the following outcomes related to the client's delusional perceptions would the nurse establish? A. The client will demonstrate realistic interpretation of daily events in the unit. B. The client will perform daily hygiene and grooming without assistance. C. The client will take prescribed medications without difficulty. D. The client will participate in unit activities

A. The client will demonstrate realistic interpretation of daily events in the unit. A client with schizophrenia, paranoid type, has distorted perceptions and views people, institutions, and aspects of the environment as plotting against him. The desired outcome for someone with delusional perceptions would be to have a realistic interpretation of daily events.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ANS: A maintain normal salt and fluids in the diet Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ANS: B Disturbed sleep pattern Patients with mood disorders, both depression and mania, experience sleep pattern disturbances.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse:

ANS: B invites the patient to sit together and look at new fashion magazines. Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ursula has sought counseling for persistent depressive disorder. She identifies that she has "always had low self-esteem" and says "I just let people walk all over me." The nurse is providing psycho-educational groups on improving self-esteem. Ursula would likely benefit from education on which of the following topics?

Assertive communication

The nurse calls security and has physical restraints applied when a client who admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. A. Libel B. Battery C. Assault D. Slander E. False Imprisonment

B, C, and E. False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a patient from leaving the hospital if the patient has been admitted voluntarily and if no agency or legal policies exist for detaining the patient. Assault and battery are related to the act of restraining the patient in a situation that did not meet criteria for such an intervention.

82-year-old Mr. Robeson together with his daughter arrived at the medical-surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis? A. "Maybe it's just caused by aging. This usually happens by age 82." B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." C. "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast." D. "Dad has always been so independent. He's lived alone for years since mom died."

B. "The changes in his behavior came on so quickly! I wasn't sure what was happening." Delirium is an acute process characterized by abrupt, spontaneous cognitive dysfunction.

Nurse Winona educates the family about symptom management for when the schizophrenic client becomes upset or anxious. Which of the following would Nurse Winona state is helpful?

B. Encourage the use of learned relaxation techniques. The client with schizophrenia can learn relaxation techniques, which help reduce anxiety. The family can be supportive and helpful by encouraging the client to use these techniques.

The parents of a young man with schizophrenia express feelings of responsibility and guilt for their son's problems. How can the nurse best educate the family? A. Acknowledge the parent's responsibility. B. Explain the biological nature of schizophrenia. C. Refer the family to a support group D. Teach the parents various ways they must change.

B. Explain the biological nature of schizophrenia. The parents are feeling responsible and this inappropriate self-blame can be limited by supplying them with the facts about the biologic basis of schizophrenia.

A 50-year-old woman brings her mother to the hospital for a mental health assessment. The woman states that her mother is verbally abusive toward her, has thrown items at her when she visits, and has called the woman's employer to complain about her. What response from the nurse is most appropriate? A. Make arrangements to have the daughter speak with the staff of a nursing home to see how they handle abusive residents B. Explore options for limiting time with the mother while she can still receive care C. Tell the woman that she should call the police the next time her mother hits her D. Remind the patient that her mother probably doesn't have much time left and she should continue to manage, even though it is difficult

B. Explore options for limiting time with the mother while she can still receive care In some caregiving situations, adults caring for aging parents are the targets of verbal and physical abuse by the older adult. This can be very difficult for a person to deal with when a parent is fragile in older age and yet still abusive. When this occurs, such as in the example, the patient may need to limit contact with the abusive parent or find other resources for care that would allow the parent to still be cared for but not at the expense of the child.

Dementia, unlike delirium, is characterized by: A. Slurred speech B. Insidious onset C. Clouding of consciousness D. Sensory perceptual change

B. Insidious onset Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances.

Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence?

Delusions, Hallucinations, Loose associations

Which nursing intervention is most appropriate for a client with Alzheimer's disease who has frequent episodes emotional lability? A. Attempt humor to alter the client mood. B. Explore reasons for the client's altered mood. C. Reduce environmental stimuli to redirect the client's attention. D. Use logic to point out reality aspects.

C. Reduce environmental stimuli to redirect the client's attention. The client with Alzheimer's disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client's attention.

Mrs. Jordan is an elderly client diagnosed with Alzheimer's disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A. tell the client firmly that it is time to get dressed. B. obtain assistance to restrain the client for safety. C. remain calm and talk quietly to the client. D. call the doctor and request an order for sedation.

C. Remain calm and talk quietly to the client. Maintaining a calm approach when intervening with an agitated client is extremely important.

The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client: A. Receives adequate nutrition and hydration B. Will reminisce to decrease isolation C. Remains in a safe and secure environment D. Independently performs self care

C. Remains in a safe and secure environment Safety is a priority consideration as the client's cognitive ability deteriorates.. A is appropriate interventions because the client's cognitive impairment can affect the client's ability to attend to his nutritional needs, but it is not the priority B. Patient is allowed to reminisce but it is not the priority. D. The client in the moderate stage of Alzheimer's disease will have difficulty in performing activities independently

A depressed patient is threatening to harm himself. Which nursing action indicates an understanding of the appropriate care of the suicidal patient? A. The nurse administers a sedative. B. The nurse places the patient in seclusion. C. The nurse asks the patient if he has a plan. D. The nurse calls the family and asks them to visit the patient.

C. The nurse asks the patient if he has a plan

A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?

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

A client informs the nurse that they are hearing voices, what is the first thing the nurse should do? A. Distract the client with the nice weather outside B. Ignore the client so they know you are not going to play games C. Tell the client the voices are not real D. Ask the client what the voices are saying

D. Ask the client what the voices are saying Finding out what the voices are saying is the most important thing to do for safety of the client, staff and other clients.

A family member expresses concern to a nurse about behavioral changes in an elderly aunt. Which would cause the nurse to suspect a cognitive impairment disorder? A. Decreased interest in activities that she once enjoyed B. Fearfulness of being alone at night C. Increased complaints of physical ailments D. Problems with preparing a meal or balancing her checkbook

D. Problems with preparing a meal or balancing her checkbook Making a meal and balancing a checkbook are higher level cognitive functions that, when unable to be performed, may signal onset of a cognitive disorder.

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

Diaphoresis, weakness, and nausea these are early signs of lithium toxicity.

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

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

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply.

Limit credit card access. Provide a structured environment. Monitor the patient's sleep patterns.

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply.

Provide a structured environment for the patient. Ensure that the patient's nutritional needs are met. People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior.

Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with:

D. Motivation for activities. In a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of motivation for activities, is a common problem.

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?

"I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness." The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. Reminding the client that "the voices" are a part of his or her illness is a way to help the client accept that the hallucinations are not real.

In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question, "How long do I have to stay here?" (Select all that apply) 1. "You may leave the hospital at any time unless you are suicidal." 2. "Let's talk more after the health team has assessed you." 3. "Once you've signed the papers, you have no say." 4. "Because you could hurt yourself, you must be safe before being discharged." 5. "You need a lawyer to help you make that decision." 6. "There must be a court hearing before you leave the hospital."

1, 2, and 4 A person who is admitted to a psychiatric hospital on a voluntary basis may sign out of the hospital unless the health care team determines that the person is harmful to himself or others. The health care team evaluates the client's condition before discharge. If there is reason to believe that the client is harmful to himself or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Option 3 is incorrect because it denies the client's rights; option 5 is incorrect because the client doesn't need a lawyer to leave the hospital; and option 6 is incorrect because a hearing isn't mandated before discharge. A hearing is held only if the client remains unsafe and requires further treatment.

Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as: A. Hallucinations B. Delusions C. Loose associations D. Neologisms

A. Hallucinations

A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms? A. benztropine (Cogentin) B. dantrolene (Dantrium) C. clonazepam (Klonopin) D. diazepam (Valium)

A. benztropine (Cogentin)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ANS: B The listed health problems are all forms of dementia.

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

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

Which of the following will Nurse Dory use when communicating with a client who has cognitive impairment. A. Complete explanations with multiple details B. Pictures or gestures instead of words C. Stimulating words and phrases to capture the client's attention D. Short words and simple sentences

D. Short words and simple sentences Short words and simple sentences minimize client confusion and enhance communication.

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

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

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

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

Which ability should Nurse Rebecca expect from a client in the mild stage of dementia of the Alzheimer's type? A. Remembering the daily schedule B. Recalling past events C. Coping the anxiety D. Solving problems of daily living

B. Recalling past events Recent memory loss is the characteristic sign of cognitive difficulty in early Alzheimer's disease. The ability to recall past events is usually retained until the later stages of this disorder.

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been plated in the unit walls. Which action would be the most therapeutic response?

B. Tell Gio that this must seem frightening to him but that you believe he is safe here. The nurse must realize that these perceptions are very real to the client. Acknowledging the client's feelings provides support; explaining how the nurse sees the situation in a different way provides reality orientation

The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered? A. To reduce psychotic symptoms B. To reduce extrapyramidal symptoms C. To control nausea and vomiting D. To relieve anxiety

B. To reduce extrapyramidal symptoms

The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: A. delusions. B. hallucinations. C. loose associations. D. neologisms.

B. hallucinations.

A nurse notes that a client with schizophrenia and receiving an antipsychotic medication is having uncontrolled movement of the lips and tongue. The nurse determines that the client is experiencing? A. Hypertensive crisis. B. Parkinsonism. C. Tardive dyskinesia. D. Neuroleptic malignant syndrome.

C. Tardive dyskinesia. Tardive dyskinesia is characterized by uncontrollable involuntary movements of the body and extremities (especially of the face, lips, mouth, tongue, arms or legs).

Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: A. Denies confusion by being jovial. B. Pretends to be someone else. C. Rationalizes various behaviors. D. Fills in memory gaps with fantasy.

D. Fills in memory gaps with fantasy. Confabulation is a communication device used by patients with dementia to compensate for memory gaps.

A 75-year-old client has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: A. Denies confusion by being jovial. B. Pretends to be someone else. C. Rationalizes various behaviors. D. Fills in memory gaps with fantasy.

D. Fills in memory gaps with fantasy. Confabulation is a communication device used by patients with dementia to compensate for memory gaps. The remaining answer choices are incorrect.

A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse "Yes, its march, March is little woman". That's literal you know". These statement illustrate: A. Neologisms B. Echolalia C. Word salad D. Loosening of association

D. Loosening of association

A student nurse was asked which of the following best describes dementia. Which of the following best describes the condition?

D. Loss of cognitive abilities, impairing ability to perform activities of daily living The impaired ability to perform self-care is an important measure of a client's dementia progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal activities of daily living, such as maintaining hygiene and grooming, toileting, making meals, and maintaining a household, are significant indications of dementia.

Drogo who has had auditory hallucinations for many years tells Nurse Khally that the voices prevent his participation in a social skills training program at the community health center. Which intervention is most appropriate?

D. Teach Drogo to use thought stopping techniques. Clients with long-lasting auditory hallucinations can learn to use thought stopping measures to accomplish tasks.

Which of the following outcome criteria is appropriate for the client with dementia? A. The client will return to an adequate level of self-functioning. B. The client will learn new coping mechanisms to handle anxiety. C. The client will seek out resources in the community for support. D. The client will follow an established schedule for activities of daily living.

D. The client will follow an established schedule for activities of daily living. Following established activity schedules is a realistic expectation for clients with dementia.

Which of the following outcome criteria is appropriate for the client with dementia? A. The client will return to an adequate level of self-functioning. B. The client will learn new coping mechanisms to handle anxiety. C. The client will seek out resources in the community for support. D. The client will follow an establishing schedule for activities of daily living.

D. The client will follow an establishing schedule for activities of daily living. Following established activity schedules is a realistic expectation for clients with dementia.

Which information is the most essential in the initial teaching session for the family of a young adult recently diagnosed with schizophrenia? A. Symptoms of this disease imbalance in the brain. B. Genetic history is an important factor related to the development of schizophrenia. C. Schizophrenia is a serious disease affecting every aspect of a person's functioning. D. The distressing symptoms of this disorder can respond to treatment with medications.

D. The distressing symptoms of this disorder can respond to treatment with medications. This statement provides accurate information and an element of hope for the family of a schizophrenic client.

During the home visit of a client with dementia, the nurse notes that an adult daughter persistently corrects her father's misperceptions of reality, even when the father becomes upset and anxious. Which intervention should the nurse teach the caregiver? A. Anxiety-reducing measures B. Positive reinforcement C. Reality orientation techniques D. Validation techniques

D. Validation techniques Validation techniques are useful measures for making emotional connections with a client who can no longer maintain reality orientation. These measures are also helpful in decreasing anxiety.

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia?

The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence.

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?

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

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?

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

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect?

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

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?

The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment?

The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment?

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

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

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

A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

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

Which statement should indicate to a nurse that an individual is experiencing a delusion?

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

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia?

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

A college student has quit attending classes, isolates self due to hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize?

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