1.2

A patient diagnosed with schizophrenia begins to talks about "cracklomers" in the local shopping mall. The term "cracklomers" should be documented as: a. neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the patient. "Cracklomers" is not a known word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others that are implanted in one's mind. An idea of reference is a type of delusion in which trivial events are given personal significance. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 312 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation. DIF: Cognitive Level: Application (Applying) REF: Pages: 324-325 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back; opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies that require immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis; it appears after prolonged treatment. Waxy flexibility is a symptom observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting. DIF: Cognitive Level: Application (Applying) REF: Page: 331 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient experiencing mania has not eaten or slept for 3 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 physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury. DIF: Cognitive Level: Application (Applying) REF: Pages: 288-289 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Safe, Effective Care Environment

The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

ANS: A At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances. DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 281-282 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

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

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately; therefore, the intramuscular route is best. In this case, the best option given is diphenhydramine. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 331 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should: a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. teach the patient how to use pursed-lip breathing.

ANS: A Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Pursed-lip breathing is irrelevant. DIF: Cognitive Level: Application (Applying) REF: Pages: 265-267 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Monitoring pupillary responses d. Assisting the patient to identify and test negative thoughts

ANS: A During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Monitoring pupillary responses is not a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused. DIF: Cognitive Level: Application (Applying) REF: Pages: 271-273 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome for the nursing diagnosis: Situational low self-esteem, related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date) . b. consent to take antidepressant medication regularly by (date) . c. initiate social interaction with another person daily by (date) . d. identify two personal behaviors that alienate others by (date) .

ANS: A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept. DIF: Cognitive Level: Application (Applying) REF: Page: 247 | Page: 259 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective approach to communication. a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require "yes" or "no" answers. d. Frequently reassure the patient to reduce guilt feelings.

ANS: A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness. DIF: Cognitive Level: Application (Applying) REF: Pages: 260-261 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

ANS: A Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for nonadherence. The incorrect options do not address the patient's dislike of taking pills. DIF: Cognitive Level: Application (Applying) REF: Page: 326 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient himself or herself to a pressured work schedule.

ANS: A Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient himself or herself to a pressured work schedule is less relevant than the correct rationale. DIF: Cognitive Level: Application (Applying) REF: Pages: 271-273 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient. DIF: Cognitive Level: Application (Applying) REF: Pages: 318-319 | Pages: 323-325 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

ANS: A Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 275 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques

ANS: A Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patient's support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 259-261 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

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

ANS: A Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information. DIF: Cognitive Level: Application (Applying) REF: Page: 296 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful. DIF: Cognitive Level: Application (Applying) REF: Page: 296 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

ANS: A The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate. DIF: Cognitive Level: Application (Applying) REF: Page: 272 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. "Converses without interrupting; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior. DIF: Cognitive Level: Application (Applying) REF: Pages: 299-300 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

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. Select the best initial approach by the nurse. 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 a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger. DIF: Cognitive Level: Application (Applying) REF: Page: 290 | Pages: 292-293 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

ANS: A The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L. DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 294-295 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

. A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then 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. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

ANS: A The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patient's mood. A high level of suspicion is not evident. DIF: Cognitive Level: Application (Applying) REF: Pages: 282-284 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are considered aggressive and usually promote violence. Patients often perceive foods in sealed containers, packages, or natural shells as being safe. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 318-321 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

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

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient. DIF: Cognitive Level: Application (Applying) REF: Page: 326 | Page: 330 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, which are the symptoms present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that are more likely to be apparent during the acute stage of the illness. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 308 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of Disturbed thought processes. Risk for other-directed violence is substantiated by the patient's paranoia and feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses. DIF: Cognitive Level: Application (Applying) REF: Pages: 316-317 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity Chapter 15: Mood Disorders: Depression Varcarolis: Essentials to Psychiatric Mental Health Nursing, 2nd Edition - Revised Reprint

A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply. a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids. d. Restrain the patient in bed with padded limb restraints. e. Assist the patient to prepare an advance directive.

ANS: A, B, C The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment. DIF: Cognitive Level: Application (Applying) REF: Pages: 271-273 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict the intake of processed foods.

ANS: A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. DIF: Cognitive Level: Application (Applying) REF: Pages: 258-259 | Page: 262 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A, C, D, F Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self. DIF: Cognitive Level: Application (Applying) REF: Pages: 258-259 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply. a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress

ANS: A, D Compelling evidence exists that schizophrenia is a neurologic disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Stress and family disruption may contribute but are not considered etiologic factors. Environmental factors are not recognized as causative variables in schizophrenia. DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 306-307 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, "I took a few extra tablets earlier in the day and now I feel bad." Which aspects of the nursing assessment are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Increased suicidal ideation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

ANS: A, D, E The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 267 | Page: 270 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity Chapter 16: Bipolar Spectrum Disorders Varcarolis: Essentials to Psychiatric Mental Health Nursing, 2nd Edition - Revised Reprint

A patient diagnosed with major depressive disorder repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

ANS: B A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 255 | Page: 259 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

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

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest. DIF: Cognitive Level: Application (Applying) REF: Pages: 290-293 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient says to the nurse, "My life does not have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint? a. Vegetative symptom b. Anhedonia c. Euphoria d. Anergia

ANS: B Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Vegetative symptoms refer to somatic changes associated with depression. Euphoria refers to an elated mood. Anergia means without energy. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 255 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A priority nursing intervention for a patient diagnosed with major depressive disorder is: a. distracting the patient from self-absorption. b. carefully and inconspicuously observing the patient around the clock. c. allowing the patient to spend long periods alone in self-reflection. d. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.

ANS: B Approximately two thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 255 | Pages: 259-260 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being exceptionally hard on yourself when you say those things." d. "How does your belief in fate relate to your cultural heritage?"

ANS: B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses are judgmental, irrelevant to an overgeneralization, and cast doubt without requiring the patient to evaluate the statement. DIF: Cognitive Level: Application (Applying) REF: Page: 261 | Pages: 263-264 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

ANS: B Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone. DIF: Cognitive Level: Application (Applying) REF: Page: 312 | Page: 320 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's best response. a. "A high proportion of patients diagnosed with bipolar disorders are found among creative writers." b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder." c. "Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses." d. "More individuals diagnosed 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 of bipolar disorder. DIF: Cognitive Level: Application (Applying) REF: Pages: 281-282 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

This nursing diagnosis applies to a patient experiencing 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 the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 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 mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in 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 will eat or drink. Appropriate attire is unrelated to the nursing diagnosis. DIF: Cognitive Level: Application (Applying) REF: Page: 291 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Physiological Integrity

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

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 315 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5?2'6?3? tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B Lurasidone HCl (Latuda) is an atypical antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management is especially important. The incidence of tardive dyskinesia is low with atypical antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 328-329 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide 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 is used for long-term control. DIF: Cognitive Level: Application (Applying) REF: Page: 294 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent

ANS: B Mood is a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. DIF: Cognitive Level: Application (Applying) REF: Pages: 255-257 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

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

ANS: B Olanzapine is an atypical antipsychotic medication that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotic agents that target only positive symptoms. Diphenhydramine is an antihistamine. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 325-326 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patient's ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition. DIF: Cognitive Level: Application (Applying) REF: Page: 314 | Page: 316 TOP: Nursing Process: Outcomes Identification MSC: NCLEX: Psychosocial Integrity

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

ANS: B Patients diagnosed with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid volume. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 288 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

ANS: B Patients taking MAOIs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 271 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. "You look nice this morning." b. "You are wearing a new shirt." c. "I like the shirt you're wearing." d. "You must be feeling better today."

ANS: B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as an observation avoid negative interpretations. Saying "You look nice" or "I like your shirt" gives approval (nontherapeutic techniques). Saying "You must be feeling better today" is an assumption, which is nontherapeutic. DIF: Cognitive Level: Application (Applying) REF: Pages: 259-261 | Pages: 263-264 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior

ANS: B Patients with disorganization demonstrate the most regressed and socially impaired behaviors. Communication is often incoherent, with silly giggling and loose associations predominating. Highly suspicious, delusional behavior relates more to paranoia. Extremes of motor activity, from excitement to stupor, relate to catatonia. Severe anxiety and ritualistic behaviors relate to obsessive-compulsive disorder. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 315 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security

ANS: B Physiologic needs must be met to preserve life. A patient who is catatonic may need to be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiologic integrity. The assessment findings do not suggest safety concerns. Higher level needs (psychosocial and self-actualization) are of lesser concern. DIF: Cognitive Level: Application (Applying) REF: Page: 314 | Page: 317 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument. DIF: Cognitive Level: Application (Applying) REF: Pages: 320-323 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient experiencing acute mania 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 most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to the staff's advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 284 | Page: 289 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet.

ANS: B Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy. DIF: Cognitive Level: Application (Applying) REF: Page: 265 | Page: 270 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are observed. These symptoms are frequently not reversible, even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes. DIF: Cognitive Level: Application (Applying) REF: Page: 332 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. 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 patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury. DIF: Cognitive Level: Application (Applying) REF: Pages: 289-291 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on the patient's 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 the 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. DIF: Cognitive Level: Application (Applying) REF: Pages: 290-291 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

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

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 313 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Criteria for seclusion have not been met. DIF: Cognitive Level: Application (Applying) REF: Pages: 289-290 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

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

ANS: B, E Stabilization is maximized by the adherence to the antipsychotic medication regimen. Because so many patients with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiologic well-being. The other topics are also important but are not priority topics. DIF: Cognitive Level: Application (Applying) REF: Page: 305 | Pages: 317-325 TOP: Nursing Process: Planning| Nursing Process: Outcomes Identification MSC: NCLEX: Health Promotion and Maintenance

When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

ANS: C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned. DIF: Cognitive Level: Application (Applying) REF: Pages: 261-262 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy. DIF: Cognitive Level: Application (Applying) REF: Pages: 294-295 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief.

ANS: C Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 267-270 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. 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 deficit and sad mood

ANS: C Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania. DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 282-287 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 313-314 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. consults the pharmacist when selecting over-the-counter medications. d. can identify foods with high selenium content, which should be avoided.

ANS: C Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 270-271 | Page: 273 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach. DIF: Cognitive Level: Application (Applying) REF: Page: 285 | Pages: 290-291 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 326 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.

ANS: C Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 288-291 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

A patient diagnosed with bipolar disorder has rapid 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. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

ANS: C Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes. DIF: Cognitive Level: Application (Applying) REF: Pages: 295-297 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Asking other patients to talk incorrectly shifts responsibility for intervention from the nurse to other patients. DIF: Cognitive Level: Application (Applying) REF: Page: 320 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: C The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils. DIF: Cognitive Level: Application (Applying) REF: Page: 291 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes. DIF: Cognitive Level: Application (Applying) REF: Pages: 288-289 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse should advise the patient: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider." d. "Resume taking the antidepressant for 2 more weeks, and then discontinue it again."

ANS: C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing. DIF: Cognitive Level: Application (Applying) REF: Pages: 265-267 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 315 | Page: 317 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient's employment is terminated and major depressive disorder results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

ANS: C The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to justify the other diagnoses. DIF: Cognitive Level: Application (Applying) REF: Page: 259 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 297 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C, D, E Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is the lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations. DIF: Cognitive Level: Application (Applying) REF: Pages: 255-264 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

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

ANS: D A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proved successful, considering the behavior has continued. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness. DIF: Cognitive Level: Application (Applying) REF: Pages: 290-293 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

ANS: D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues. DIF: Cognitive Level: Application (Applying) REF: Page: 266 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)

ANS: D Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 325-329 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

ANS: D During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation. DIF: Cognitive Level: Application (Applying) REF: Page: 296 | Page: 298 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

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

ANS: D Learning what a command hallucination is telling the patient to do is important; the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command. DIF: Cognitive Level: Application (Applying) REF: Page: 317 | Page: 320 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment

A patient diagnosed with schizophrenia says, "High heat. Last time here. Did you get a coat?" What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 311 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food? a. Tomato juice b. Orange juice c. Hot tea d. Milk

ANS: D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins. DIF: Cognitive Level: Application (Applying) REF: Page: 262 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

ANS: D Nonverbal communication is usually considered more powerful than verbal communication. Downward-casted eyes suggest feelings of worthlessness or hopelessness. DIF: Cognitive Level: Application (Applying) REF: Page: 260 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.

ANS: D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Guilt and despair might be observed when the nurse experiences feelings about patients because of sympathy. Interest is possible but not the most likely result. The correct response is more global than overinvolvement. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 258 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, "You are mean and nasty. No one trusts you or wants to be around you." Select the most likely analysis. The patient: a. is trying to manipulate the nurse by using negative comments. b. is likely to experience disorganization and catatonia in the near future. c. is jealous of the nurse's position of power in the relationship. d. may be identifying another person's shortcomings in order to preserve his or her own self-esteem.

ANS: D Patients with paranoid ideation often use disparaging comments to preserve one's own self-esteem. There is no evidence the patient is trying to manipulate the nurse or is jealous. This behavior is not predictive of catatonia or disorganization. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 315 | Page: 320 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is regularly taking his or her medication. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 316-318 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "The staff here cares about you and wants to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say negative things about yourself." d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

ANS: D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point. DIF: Cognitive Level: Application (Applying) REF: Pages: 260-261 | Pages: 263-264 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurse's best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, low fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

ANS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in this scenario are not consistent with the medical problems listed in the incorrect options. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 331-332 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

ANS: D The 40-year-old patient who has been diagnosed with schizophrenia since 18 years of age could logically be expected to have the lowest overall level of functioning secondary to deterioration associated with frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have a higher level because schizophrenia of short duration may be less impairing than other types. The patient who has had episodes of catatonia since the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient diagnosed with schizophreniform disorder has been ill for only 6 months, and disability is likely to be minimal. DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 308 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of "cheeking" the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 294-295 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: D The patient is describing phenomena that indicate personal boundary difficulties. The nurse should maintain an appropriate social distance and not touch the patient, because the patient is anxious about the inability to maintain ego boundaries and merging with or being swallowed by the environment. Physical closeness or touch could precipitate panic. DIF: Cognitive Level: Application (Applying) REF: Page: 313 | Pages: 318-321 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: D The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on the hallucinatory clue (i.e., the patient's laughter) and then eliciting the patient's observation is best. The incorrect options are less useful in eliciting a response; no joke may be involved, "Why" questions are difficult to answer, and the patient is probably not focusing on what the nurse has said in the first place. DIF: Cognitive Level: Application (Applying) REF: Page: 320 | Pages: 322-323 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with schizophrenia says, "Everyone has skin lice that jump on you and contaminate your blood." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of contamination indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information. DIF: Cognitive Level: Application (Applying) REF: Page: 315 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. This baby is the root of my problems." The priority nursing diagnosis is: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence

ANS: D When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority. DIF: Cognitive Level: Application (Applying) REF: Page: 253 TOP: Nursing Process: Diagnosis| Nursing Process: Analysis MSC: NCLEX: Health Promotion and Maintenance

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

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. DIF: Cognitive Level: Application (Applying) REF: Pages: 318-323 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

Patients diagnosed with schizophrenia who are suspicious and withdrawn: a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior. DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 309 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, "You must bathe daily." d. firmly and neutrally assist the patient with showering.

ANS: D When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive. DIF: Cognitive Level: Application (Applying) REF: Pages: 260-262 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that

No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?" !ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking "why" does not provide for environmental safety. DIF: Cognitive Level: Application (Applying) REF: Pages: 290-293 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment