Combined Psych Test 3

During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response?

"Psychological factors, like excessive stress, have been found to affect medical conditions."

Which nursing statement about the concept of neuroses is most accurate?

"An individual experiencing neurosis feels helpless to change his or her situation."

A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to: 1. take the client's vital signs. 2. explore the content of the hallucinations. 3. tell him his fear is unrealistic. 4. engage the client in reality-oriented activities.

A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to: 1. take the client's vital signs. 2. explore the content of the hallucinations. 3. tell him his fear is unrealistic. 4. engage the client in reality-oriented activities. Correct Answer: 2 RATIONALES: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

Which client should the nurse anticipate to be most receptive to psychiatric treatment?

A Jewish, female journalist

According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?

A client exhibiting aggressive behavior toward another client

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? 1. Take the medication 1 hour before a meal. 2. Decrease the dosage if signs of illness decrease. 3. Apply a sunscreen before exposure to the sun. 4. Increase the dosage up to 50 mg twice per day if signs of illness don't decrease.

A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client? 1. Take the medication 1 hour before a meal. 2. Decrease the dosage if signs of illness decrease. 3. Apply a sunscreen before exposure to the sun. 4. Increase the dosage up to 50 mg twice per day if signs of illness don't decrease. Correct Answer: 3 RATIONALES: Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse also should teach the client to take haloperidol with meals, not 1 hour before. Finally, the nurse should instruct the client not to decrease or increase the dosage unless the physician orders it. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? 1. Word salad 2. Tangential 3. Perseveration 4. Avolition

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? 1. Word salad 2. Tangential 3. Perseveration 4. Avolition Correct Answer: 4 RATIONALES: Avolition refers to impairment in the ability to initiate goal-directed activity, lack of motivation, and inattention to needs such as personal hygiene and activities of daily living. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential behavior is exhibited when a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? 1. "If it had been your emergency, I would have made the other client wait." 2. "I know it's frustrating to wait. I'm sorry this happened." 3. "Can we talk about how this is making you feel right now?" 4. "I really care about you and I'll never let this happen again."

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? 1. "If it had been your emergency, I would have made the other client wait." 2. "I know it's frustrating to wait. I'm sorry this happened." 3. "Can we talk about how this is making you feel right now?" 4. "I really care about you and I'll never let this happen again." Correct Answer: 3 RATIONALES: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option 1 wouldn't address the client's anger. Option 2 is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option 4, because such matters are outside the nurse's control. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination.

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination. Correct Answer: 4 RATIONALES: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client with schizophrenia is admitted to the facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply: 1. Delusions 2. Hallucinations 3. Apathy 4. Blunted affect 5. Lack of motivation

A client with schizophrenia is admitted to the facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? Select all that apply: 1. Delusions 2. Hallucinations 3. Apathy 4. Blunted affect 5. Lack of motivation Correct Answer: 3,4,5 RATIONALES: Negative symptoms of schizophrenia reflect the absence of normal characteristics. They include apathy, lack of motivation, blunted affect, poverty of speech, anhedonia (diminished capacity to experience pleasure), and antisocial behavior. Positive symptoms of schizophrenia include delusions and hallucinations. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension

A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse effects. Which nursing measures should the nurse take during haloperidol administration? Select all that apply: 1. Review subcutaneous injection technique. 2. Closely monitor vital signs, especially temperature. 3. Provide the client with the opportunity to pace. 4. Monitor blood glucose levels. 5. Provide the client with hard candy. 6. Monitor for signs and symptoms of urticaria.

A physician starts a client on the antipsychotic medication haloperidol (Haldol). The nurse is aware that this medication has extrapyramidal adverse effects. Which nursing measures should the nurse take during haloperidol administration? Select all that apply: 1. Review subcutaneous injection technique. 2. Closely monitor vital signs, especially temperature. 3. Provide the client with the opportunity to pace. 4. Monitor blood glucose levels. 5. Provide the client with hard candy. 6. Monitor for signs and symptoms of urticaria. Correct Answer: 2,3,5 RATIONALES: Neuroleptic malignant syndrome is a life-threatening extrapyramidal adverse effect of antipsychotic medications such as haloperidol. It's associated with a rapid increase in temperature. The most common extrapyramidal adverse effect, akathisia, is a form of psychomotor restlessness that can often be relieved by pacing. Haloperidol and the anticholinergic medications that are provided to alleviate its extrapyramidal effects can result in dry mouth. Providing the client with hard candy to suck on can help alleviate this problem. Haloperidol isn't given subcutaneously and doesn't affect blood glucose levels. Urticaria isn't usually associated with haloperidol administration. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Analysis

Which should the nurse recognize as an example of the defense mechanism of repression?

A woman was raped when she was 12 and no longer remembers the incident.

When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize? A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder

ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT.

A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. Based on this observation, which is the most appropriate nursing action? A. The nurse notifies the client's physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT treatment room. C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the client's fluid intake to facilitate the digestive process.

ANS: A A client who is scheduled for ECT treatments is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment.

A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT treatments, a nurse should recognize the continued need for which critical intervention? A. Suicide assessment must continue throughout the ECT course of treatment. B. Antidepressant medications are contraindicated throughout the ECT course of treatment. C. Discourage expressions of hopelessness throughout the ECT course of treatment. D. Encourage high-caloric diet throughout the ECT course of treatment.

ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom. Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations.

Immediately after an initial electroconvulsive therapy (ECT) treatment a client states, "I'm not hungry and just want to stay in bed and sleep." Based on this information, which is the most appropriate nursing intervention? A. Allow the client to remain in bed. B. Encourage the client to join the milieu to promote socialization. C. Obtain a physician's order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation.

ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed.

A client is scheduled for an initial treatment of electroconvulsive therapy (ECT). Which information should a nurse include when teaching about the potential side effects of this procedure? A. "You may experience transient tangential thinking." B. "You may experience some memory deficit surrounding the ECT." C. "You may experience avolution for the remainder of the day." D. "You may experience a higher risk for subsequent seizures."

ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure.

Immediately after electroconvulsive therapy, in which position should a nurse place the client? A. On his or her side to prevent aspiration B. In semi-Fowler's position to promote oxygenation C. In Trendelenburg's position to promote blood flow to vital organs D. In prone position to prevent airway blockage

ANS: A The nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment.

A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following Axis I diagnoses? (Select all that apply.) A. Major depressive disorder B. Bipolar disorder: manic phase C. Schizoaffective disorder D. Obsessive-compulsive anxiety disorder E. Body dysmorphic disorder

ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression; acute mania; and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions

During a course of 12 electroconvulsive therapy (ECT) treatments, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. At this time, which of the following nursing diagnoses should be assigned to this client? (Select all that apply.) A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Disturbed thought processes R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss

ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated.

Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT) treatments? (Select all that apply.) A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy

ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy.

Which assessment test results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? (Select all that apply.) A. Electrocardiogram graphic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results

ANS: A, B, D, E A nurse should evaluate electrocardiogram graphic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the client's physician. The client must be medically cleared prior to ECT treatment.

A nursing student is observing an electroconvulsive therapy (ECT) treatment. The student notices a blood pressure cuff on the client's lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply? A. "The cuff has to be placed on the leg because both arms are used for intravenous fluids." B. "The cuff functions to prevent succinylcholine from reaching the foot." C. "The cuff position gives a more accurate blood pressure reading during the treatment." D. "The cuff is placed on the leg so that arms can easily be restrained during seizure."

ANS: B A blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent.

A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. "During ECT a state of euphoria is induced." B. "ECT induces a grand mal seizure." C. "During ECT a state of catatonia is induced." D. "ECT induces a petit mal seizure."

ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression.

A client states, "My doctor has told me I am a candidate for electroconvulsive therapy (ECT). Where will the treatment take place and how much time would this entail?" Which is the most accurate nursing reply? A. "Clients typically receive ECT in their hospital room, daily for 1 month." B. "Clients typically receive 6 to 12 ECT treatments, three times a week in an outpatient setting." C. "Clients typically receive an unlimited number of treatments in the hospital treatment room." D. "Clients typically receive two to three treatments in either an outpatient or inpatient setting."

ANS: B Most clients require an average of 6 to 12 ECT treatments, but some may require up to 20 treatments. Treatments are usually administered every other day, three times per week. Treatments are performed on either an inpatient or outpatient basis depending on the need for client monitoring.

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

ANS: B 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.

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? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

ANS: B 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.

A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would determine the feasibility of this treatment option? A. Because the client is extremely suicidal, ECT is an appropriate option. B. Because antidepressant medications have been ineffective, ECT is a good alternative. C. Because informed consent is required for ECT, cognitive deficits preclude this option. D. Because of the client's cognitive deficits, a signed consent is waived.

ANS: C A client who is experiencing cognitive deficits cannot give informed consent that is required prior to ECT treatment. A court proceeding could determine the client's level of competency and, if necessary, appoint a guardian.

A client who is learning about electroconvulsive therapy (ECT) treatment asks a nurse "Isn't this treatment dangerous?" Which is the most appropriate nursing reply? A. "No, this treatment is side-effect free." B. "There can be temporary paralysis but full functioning returns within 3 hours of treatment." C. "There are some risks, but a thorough examination will determine your candidacy for ECT." D. "Transient ischemic attacks (TIA) can occur but are rare."

ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment.

A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT) treatments. Which student statement indicates that learning has occurred? A. "Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT." B. "Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration." C. "Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious." D. "Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure."

ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously, a short-acting anesthetic like thiopental sodium (Pentothal).

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? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.

ANS: C It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. 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.

After receiving two of nine electroconvulsive therapy (ECT) treatments, a client states, "I can't even remember eating breakfast, so I want to stop the ECT treatments." Which is the most appropriate nursing reply? A. "After you begin the course of treatments, you must complete all of them." B. "You'll need to talk with your doctor about what you're thinking." C. "It is within your right to discontinue the treatments, but let's talk about your concerns." D. "Memory loss is a rare side effect of the treatment. I don't think it should be a concern."

ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the client's concerns so that the nurse can provide needed information.

A nurse administers pure oxygen to a client during and after electroconvulsive therapy treatment. What is the nurse's rationale for this procedure? A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity

ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medication-induced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain.

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

ANS: C 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 client experienced bradycardia during electroconvulsive therapy (ECT) treatment. A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve? A. The client will verbalize an understanding of the need for moving slowly after treatment. B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment. C. The client will continue adequate tissue perfusion 1 hour after treatment. D. The client will verbalize an understanding of common side effects of ECT.

ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored.

A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a client's electroconvulsive therapy (ECT) treatment. What is the rationale for administering this medication? A. Robinul decreases anxiety during the ECT procedure. B. Robinul induces an unconscious state to prevent pain during the ECT procedure. C. Robinul prevents severe muscle contractions during the ECT procedure. D. Robinul decreases secretions to prevent aspiration during the ECT procedure.

ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT treatments to decrease secretions and prevent aspiration.

16. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response? A. Genetics have nothing to do with your temperament. B. How you reacted to past experiences influences how you feel now. C. If youre in good physical health, your stress level will be low. D. Stress can always be avoided if appropriate coping mechanisms are employed

Answer: b. How you reacted to past experiences influences how you feel now. Rationale: Past experiences are occurrences that result in learned patterns that can influence an individuals current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors.

5. A school nurse is assessing a female high school student who is overly concerned about her appearance. The clients mother states, Thats not something to be stressed about! Which is the most appropriate nursing response? A. Teenagers! They don't know a thing about real stress. B. Stress occurs only when there is a loss. C. When you are in poor physical condition, you can;t experience psychological well-being. D. Stress can be psychological. A threat to self-esteem may result in high stress levels.

Answer: d. Stress can be psychological. A threat to self-esteem may result in high stress levels. Rationale: Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change.

A new psychiatric nurse states, "This client's use of defense mechanisms should be eliminated." Which is a correct evaluation of this nurse's statement?

Defense mechanisms can be self-protective responses to stress and need not be eliminated.

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate ? 1. Approach the client and touch him to get his attention. 2. Encourage the client to go to his room where he'll experience fewer distractions. 3. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. 4. Ask the client to describe what the voices are saying.

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is appropriate ? 1. Approach the client and touch him to get his attention. 2. Encourage the client to go to his room where he'll experience fewer distractions. 3. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices. 4. Ask the client to describe what the voices are saying. Correct Answer: 3 RATIONALES: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

The nurse is developing a teaching plan for a client receiving clozapine (Clozaril). The nurse should stress the importance of which aspect of follow-up care? 1. Monthly EEGs 2. Cardiology consult 3. Echocardiogram 4. Routine complete blood count (CBC) with differential

The nurse is developing a teaching plan for a client receiving clozapine (Clozaril). The nurse should stress the importance of which aspect of follow-up care? 1. Monthly EEGs 2. Cardiology consult 3. Echocardiogram 4. Routine complete blood count (CBC) with differential Correct Answer: 4 RATIONALES: The client requires routine CBCs with differentials because clozapine can cause potentially fatal blood dyscrasia characterized by severe neutropenia. Although this adverse effect is rare, it's potentially fatal if not detected early. Monthly EEGs, a cardiology consult, and an echocardiogram aren't necessary follow-up measures for the client taking clozapine. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

Which information is important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 1. Monthly blood tests will be necessary. 2. Report a sore throat or fever to the physician immediately. 3. Blood pressure must be monitored for hypertension. 4. Stop the medication when symptoms subside.

Which information is important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 1. Monthly blood tests will be necessary. 2. Report a sore throat or fever to the physician immediately. 3. Blood pressure must be monitored for hypertension. 4. Stop the medication when symptoms subside. Correct Answer: 2 RATIONALES: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/μl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

Which nursing statement about the concept of psychoses is most accurate?

"Individuals experiencing psychoses experience little distress."

Which statement reflects a student nurse's accurate understanding of the concepts of mental health and mental illness?

"The concepts are multidimensional and culturally defined."

Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?

"Yes, it was a difficult relationship, but I think I have learned from the experience."

A 62-year-old male client with paranoid schizophrenia tells a nurse that he wants to die. After further discussion, the nurse discovers that the client doesn't have a suicide plan. Which response by the nurse is appropriate? 1. "I feel like that sometimes. Don't worry, you'll feel better soon." 2. "I would like to explore your thoughts further. Can you tell me more?" 3. "Excuse me while I discuss your thoughts with my nursing supervisor." 4. "When your medications reach therapeutic levels, you'll no longer have those feelings."

A 62-year-old male client with paranoid schizophrenia tells a nurse that he wants to die. After further discussion, the nurse discovers that the client doesn't have a suicide plan. Which response by the nurse is appropriate? 1. "I feel like that sometimes. Don't worry, you'll feel better soon." 2. "I would like to explore your thoughts further. Can you tell me more?" 3. "Excuse me while I discuss your thoughts with my nursing supervisor." 4. "When your medications reach therapeutic levels, you'll no longer have those feelings." Correct Answer: 2 RATIONALES: The nurse's use of active listening and therapeutic communication allows the client to explore his thoughts more fully. Telling the client not to worry offers false reassurance. The nurse should obtain more data from the client before reporting the incident to her nursing supervisor. Advising the client that medications will change his feelings could falsely reassure the client; he might not feel better after medications reach therapeutic levels. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Coordinated care COGNITIVE LEVEL: Analysis

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination.

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing: 1. a delusion. 2. flight of ideas. 3. ideas of reference. 4. a hallucination. Correct Answer: 3 RATIONALES: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. A delusion is a false belief. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for a hallucinating client is to: 1. take an as-needed dose of psychotropic medication whenever he hears voices. 2. practice saying "Go away" or "Stop" when he hears voices. 3. sing loudly to drown out the voices and provide a distraction. 4. go to his room until the voices go away.

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for a hallucinating client is to: 1. take an as-needed dose of psychotropic medication whenever he hears voices. 2. practice saying "Go away" or "Stop" when he hears voices. 3. sing loudly to drown out the voices and provide a distraction. 4. go to his room until the voices go away. Correct Answer: 2 RATIONALES: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as-needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: 1. delusion of persecution. 2. delusion of grandeur. 3. somatic delusion. 4. jealous delusion.

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: 1. delusion of persecution. 2. delusion of grandeur. 3. somatic delusion. 4. jealous delusion. Correct Answer: 3 RATIONALES: Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one's importance, wealth, power, or talents. Jealous delusions are delusions that one's spouse or lover is unfaithful. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A delusional client approaches the nurse, stating, "I am the Easter bunny," and insisting that the nurse refer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply: 1. Consistently use the client's name in interaction. 2. Smile at the humor of the situation. 3. Agree that the client is the Easter Bunny. 4. Logically point out why the client could not be the Easter Bunny. 5. Provide an as-needed medication. 6. Provide the client with structured activities.

A delusional client approaches the nurse, stating, "I am the Easter bunny," and insisting that the nurse refer to him as such. The belief appears to be fixed and unchanging. Which nursing interventions should the nurse implement when working with this client? Select all that apply: 1. Consistently use the client's name in interaction. 2. Smile at the humor of the situation. 3. Agree that the client is the Easter Bunny. 4. Logically point out why the client could not be the Easter Bunny. 5. Provide an as-needed medication. 6. Provide the client with structured activities. Correct Answer: 1,6 RATIONALES: Continued reality-based orientation is necessary, so it's appropriate to use the client's name in any interaction. Structured activities can help the client refocus and resolve his delusion. The nurse shouldn't contribute to the delusion by going along with the situation or smiling at the humor of the circumstances. Logical arguments and an as-needed medication aren't likely to change the client's beliefs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic? 1. "I don't hear the voice, but I know you hear what sounds like a voice." 2. "You shouldn't focus on that voice." 3. "Don't worry about the voice as long as it doesn't belong to anyone real." 4. "King Tut has been dead for years."

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic? 1. "I don't hear the voice, but I know you hear what sounds like a voice." 2. "You shouldn't focus on that voice." 3. "Don't worry about the voice as long as it doesn't belong to anyone real." 4. "King Tut has been dead for years." Correct Answer: 1 RATIONALES: This response states reality about the client's hallucination. The other options aren't therapeutic. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

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? A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference

ANS: D 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.

Which is an example of the ego defense mechanism of regression?

An adult throws a temper tantrum when he does not get his own way.

13. Which symptom should a nurse identify as typical of the fight-or-flight response? A. Pupil constriction. B. Decreased heart rate. C. Increased salivation. D. Decreased peristalsis.

Answer: D

A nurse is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptoms might the client demonstrate? Select all that apply.

Fidgeting Laughing inappropriately Nail biting

Which should the nurse recognize as a DSM-5 disorder?

Generalized anxiety disorder

Most cultures label behavior as mental illness on the basis of which of the following criteria?

Incomprehensibility and cultural relativity

The nurse is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction?

Learning is enhanced when anxiety is mild.

A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health?

Mental health is successful adaptation to stressors in the internal and external environment.

Which is the most significant consequence of the excessive use of defense mechanisms?

Problem-solving will be limited.

Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM-5?

Somatic symptom disorders

A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors?

The client's behaviors demonstrate no functional impairment, indicating no mental illness.

An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?

The employee criticizes a coworker

A husband accuses his wife of infidelity. Which situation would indicate to the nurse the husband's use of the ego defense mechanism of projection?

The husband has already admitted to having an affair with a coworker.

The nurse is caring for a client with schizophrenia. Which outcome should prompt a revision to the client's plan of care? 1. The client spends more time by himself. 2. The client doesn't engage in delusional thinking. 3. The client doesn't harm himself or others. 4. The client demonstrates the ability to meet his own self-care needs.

The nurse is caring for a client with schizophrenia. Which outcome should prompt a revision to the client's plan of care? 1. The client spends more time by himself. 2. The client doesn't engage in delusional thinking. 3. The client doesn't harm himself or others. 4. The client demonstrates the ability to meet his own self-care needs. Correct Answer: 1 RATIONALES: The client with schizophrenia is commonly socially isolated and withdrawn. Having the client spend more time by himself isn't a desirable outcome. The client's plan of care should be revised to reflect the outcome of spending more time with other clients and staff on the unit. The other options are desirable outcomes that don't require revisions to the client's plan of care. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

At what point should the nurse determine that a client is at risk for developing a mental disorder?

When maladaptive responses to stress are coupled with interference in daily functioning

Brandon, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. Brandon's belief is an example of a: a. Delusion of persecution. b. Delusion of reference. c. Delusion of control or influence. d. Delusion of grandeur.

a. Delusion of persecution.

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes these behaviors as a symptom of the client's illness. The most appropriate nursing intervention for this symptom is to: a. Ask the client to describe his physical symptoms. b. Ask the client to describe what he is hearing. c. Administer a dose of benztropine. d. Call the physician for additional orders.

b. Ask the client to describe what he is hearing.

The primary focus of family therapy for clients with schizophrenia and their families is: a. To discuss concrete problem-solving and adaptive behaviors for coping with stress. b. To introduce the family to others with the same problem. c. To keep the client and family in touch with the health-care system. d. To promote family interaction and increase understanding of the illness.

d. To promote family interaction and increase understanding of the illness.

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? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

ANS: A 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.

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? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

ANS: A 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 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." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

ANS: A 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. The client who hears voices is experiencing an auditory hallucination.

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? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

ANS: A 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.

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

ANS: A 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.

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?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions

ANS: A, B, C 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.

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? (Select all that apply.) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

ANS: A, B, D, E 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 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? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

ANS: A, C, E 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 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? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoid delusion." D. "The client is verbalizing a word salad."

ANS: B 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. Word salad refers to a group of words that are put together randomly.

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? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

ANS: B The nurse should focus on the client's feelings 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.

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

ANS: B 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.

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? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

ANS: B 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? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

ANS: B 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.

A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

ANS: C Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.

A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness." D. "The devil only talks to people who are receptive to his influence."

ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. 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.

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? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

ANS: C 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.

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? A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Watch your diet and try to engage in some regular physical activity." C. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."

ANS: C 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.

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? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

ANS: C 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 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? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

ANS: C 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 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? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

ANS: C 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.

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? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. 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 client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

ANS: C 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.

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.

ANS: D 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.

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? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

ANS: D 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.

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

18. A nurse is working with a client who has recently been under a great deal of stress. Which nursing recommendations would be most helpful when assisting the client in coping with stress? Select all that apply. A. Enjoy a pet. B. Spend time with a loved one. C. Listen to music. D. Focus on the stressors. E. Journal your feelings.

Answer: A, B, C, E Rationale: Focusing on the stressors is more likely to increase stress in the clients life. However, pets, music, journaling feelings, and healthy relationships have all been shown to decrease amounts of stress.

17. A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply. A. What resources have you used previously in stressful situations? B. Have you ever experienced a similar stressful situation? C. Who do you think is to blame for this situation? D. Why do you think you were fired from your job? E. What skills do you possess that might lead to gainful employment?

Answer: A, B, E Rationale: These questions specifically address the clients coping resources and encourage the client to apply learning from past experiences. These questions also encourage the client to consider alternative methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather, encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to communication.

20. A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient are common initial biological responses to stress? Select all that apply. A. Constricted pupils. B. Watery eyes. C. Unusual food cravings. D. Increased heart rate. E. Increased respirations.

Answer: B, D, E Rationale: Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. Since dilated pupils rather than constricted pupils are related to Fight or Flight syndrome, this symptom should be assessed for other potential causes. Unusual food cravings have not been identified as a typical biological response to stress.

9. Meditation has been shown to be an effective stress management technique. When meditation is effective, what should a nurse expect to assess? A. An achieved state of relaxation. B. An achieved insight into ones feelings. C. A demonstration of appropriate role behaviors. D. An enhanced ability to problem-solve.

Answer: a. An achieved state of relaxation. Rationale: Meditation produces relaxation by creating a special state of consciousness through focused concentration.

12. When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate? A. Decreased resistance to disease. B. Increased libido. C. Decreased blood pressure. D. Increased inflammatory response.

Answer: a. Decreased resistance to disease. Rationale: In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at which time the body's compensatory mechanisms no longer function effectively and diseases of adaptation occur. A decreased immune response is seen at this stage.

3. Which client statement should alert a nurse that a client may be responding maladaptively to stress? A. I've found that avoiding contact with others helps me cope. B. I really enjoy journaling; its my private time. C. I signed up for a yoga class this week. D. I made an appointment to meet with a therapist.

Answer: a. I've found that avoiding contact with others helps me cope. Rationale: Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems.

19. A nurse is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety? A. Diagnostic blood tests. B. Awareness of factors creating stress. C. Relaxation exercises. D. Identifying support systems.

Answer: b. Awareness of factors creating stress. Rationale: Although all of the above answers may be useful in the comprehensive management of stress, the initial step is awareness that stress is being experienced and awareness of factors that create stress.

6. A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time? A. Meditation B. Problem-solving training C. Relaxation D. Journaling

Answer: b. Problem-solving training Rationale: The student must assess his or her situation and determine the best course of action. Problem-solving training, by providing structure and objectivity, can assist in decision making.

8. A school nurse is assessing a distraught female high school student who is overly concerned because her parents cant afford horseback riding lessons. How should the nurse interpret the students reaction to her perceived problem? A. The problem is endangering her well-being. B. The problem is personally relevant to her. C. The problem is based on immaturity. D. The problem is exceeding her capacity to cope.

Answer: b. The problem is personally relevant to her. Rationale: Psychological stressors to self-esteem and self-image are related to how the individual perceives the situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all the advantages that other adolescents experience.

4. A nursing student finds that she comes down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing? A. Alarm reaction stage. B. Stage of resistance. C. Stage of exhaustion. D. Fight-or-flight stage.

Answer: c. Stage of exhaustion. Rationale: At the stage of exhaustion, the students exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage.

1. A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data? A. The client is experiencing severe distress and is at risk for physical and psychological illness. B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness. C. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports. D. The client may view these losses as challenges and perceive them as opportunities.

Answer: c. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports. Rationale: The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a clients life. However, positive coping mechanisms and strong social support can limit susceptibility to stress-related illnesses

14. A nurse is evaluating a clients response to stress. What would indicate to the nurse that the client is experiencing a secondary appraisal of the stressful event? A. When the individual judges the event to be benign. B. When the individual judges the event to be irrelevant. C. When the individual judges the resources and skills needed to deal with the event. D. When the individual judges the event to be pleasurable.

Answer: c. When the individual judges the resources and skills needed to deal with the event. Rationale: When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign-positive, and stressful.

7. An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention? A. Encourage the student to use the alternative coping mechanism of relaxation exercises. B. Complete the problem-solving process for the client. C. Work through the problem-solving process with the client. D. Encourage the client to keep a journal.

Answer: c. Work through the problem-solving process with the client. Rationale: During times of high anxiety and stress, clients will need more assistance in problem-solving and decision making.

10. A distraught, single, first-time mother cries and asks a nurse, How can I go to work if I cant afford childcare? What is the nurses initial action in assisting the client with the problem-solving process? A. Determine the risks and benefits for each alternative. B. Formulate goals for resolution of the problem. C. Evaluate the outcome of the implemented alternative. D. Assess the facts of the situation.

Answer: d. Assess the facts of the situation. Rationale: Before any other steps can be taken, accurate information about the situation must be gathered and assessed.

2. A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor? A. Irrelevant B. Harm/loss C. Threatening D. Challenging

Answer: d. Challenging Rationale: The client perceives the situation of job loss as a challenge and an opportunity for growth.

15. Research undertaken by Miller and Rahe in 1997 demonstrated a correlation between the effects of life change and illness. This research led to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool? A. Specific illnesses are not identified. B. The numerical values associated with specific life events are randomly assigned. C. Stress is viewed as only a physiological response. D. Personal perception of the event is excluded.

Answer: d. Personal perception of the event is excluded. Rationale: Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration.

11. A nursing instructor is asking students about diseases of adaptation and when they are likely to occur. Which student response indicates that learning has occurred? A. When an individual has limited experience dealing with stress. B. When an individual inherits maladaptive genes. C. When an individual experiences existing conditions that exacerbate stress. D. When an individuals physiological and psychological resources have become depleted.

Answer: d. When an individuals physiological and psychological resources have become depleted. Rationale: During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is the time when diseases of adaptation may occur.

How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply.

It informs the nurse of accurate and reliable medical diagnosis. It represents progress toward a more holistic view of mind-body. It provides a framework for interdisciplinary communication.

Which of the following are cultural aspects of mental illness? Select all that apply.

Local or cultural norms define pathological behavior. The higher the social class the greater the recognition of mental illness behaviors. Psychiatrists typically see patients when the family can no longer deny the illness.

A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?

Possessing a feeling of self-fulfillment and realizing full potential

A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, "I know she wants me." This statement reflects which defense mechanism?

Projection

A mental health technician asks the nurse, "How do psychiatrists determine which diagnosis to give a patient?" Which of these responses by the nurse would be most accurate?

Psychiatrists use pre-established criteria from the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, "I work hard to provide for my family. I don't see why I can't drink to relax." The nurse recognizes the use of which defense mechanism?

Rationalization

A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism?

Reaction formation

A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents?

Reactions to stress are relative rather than absolute; individual responses to stress vary.

When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?

Saying to the spouse, "I don't drink too much!"

Which of the following statements should a nurse recognize as true about defense mechanisms? Select all that apply.

They are employed when there is a threat to biological or psychological integrity. They are used in an effort to relieve mild to moderate anxiety. They are mechanisms that are characteristically self-deceptive.

Recent research on the RAISE approach to treatment of schizophrenia incorporates which of the following elements as important to improving outcomes? (Select all that apply.) a. Early intervention at the first episode of psychosis b. Support for employment and/or educational pursuits c. Rapid high-dose loading with antipsychotic medication d. Court-ordered sanctions for treatment e. Recovery-focused psychotherapy

a. Early intervention at the first episode of psychosis b. Support for employment and/or educational pursuits e. Recovery-focused psychotherapy

The primary goal in working with an actively psychotic, suspicious client would be to: a. Promote interaction with others. b. Decrease his anxiety and increase trust. c. Improve his relationship with his parents. d. Encourage participation in therapy activities.

b. Decrease his anxiety and increase trust.

Josh, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Josh is to: a. Give him an injection of Thorazine b. Ensure a safe environment for him and others. c. Place him in restraints d. Order him a nutritious diet.

b. Ensure a safe environment for him and others.

A client recently admitted to the hospital reports to the nurse, "I don't understand why I was brought here. I was simply hanging out in my apartment and the police said I had to come with them." This is an example of what symptom of schizophrenia? a. Delusions of reference b. Loose association c. Anosognosia d. Auditory hallucinations

c. Anosognosia

The nurse is interviewing a client on the psychiatric unit. The client tilts his head to the side, stops talking in midsentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing: a. Somatic delusions. b. Catatonic stupor. c. Auditory hallucinations. d. Pseudoparkinsonism.

c. Auditory hallucinations.

When a client suddenly becomes aggressive and violent on the unit, which of the following approaches would be best for the nurse to use first? a. Provide large motor activities to relieve the client's pent-up tension. b. Administer a dose of prn chlorpromazine to keep the client calm. c. Call for sufficient help to control the situation safely. d. Convey to the client that his behavior is unacceptable and will not be permitted.

c. Call for sufficient help to control the situation safely.

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Why is chlorpromazine ordered? a. To reduce extrapyramidal symptoms b. To prevent neuroleptic malignant syndrome c. To decrease psychotic symptoms d. To induce sleep

c. To decrease psychotic symptoms

Brandon, a client on the psychiatric unit, has been diagnosed with schizophrenia. He begins to tell the nurse about how the CIA is looking for him and will kill him if they find him. The most appropriate response by the nurse is: a. "That's ridiculous, Brandon. No one is going to hurt you." b. "The CIA isn't interested in people like you, Brandon." c. "Why do you think the CIA wants to kill you?" d. "I know you believe that, Brandon, but it's really hard for me to believe."

d. "I know you believe that, Brandon, but it's really hard for me to believe."

The nurse is caring for a client with schizophrenia. Orders from the physician include 100 mg chlorpromazine IM STAT and then 50 mg PO bid; 2 mg benztropine PO bid prn. Because benztropine was ordered on a prn basis, which of the following assessments by the nurse would convey a need for this medication? a. The client's level of agitation increases. b. The client complains of a sore throat. c. The client's skin has a yellowish cast. d. The client develops muscle spasms

d. The client develops muscle spasms