EXAM 2 PSYCH practice probs

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 13. Which assessment data should a school nurse recognize as signs of physical neglect? A. The child is often absent from school and seems apathetic and tired. B. The child is very insecure and has poor self-esteem. C. The child has multiple bruises on various body parts. D. The child has sophisticated knowledge of sexual behaviors.

A The nurse should recognize that a child who is often absent from school and seems apathetic and tired might be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

Cognitive Level: Analysis | Integrated Processes: Communication and Documentation; Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 13. Which statement should indicate to a nurse that an individual is experiencing a delusion? A. Theres an alien growing in my liver. B. I see my dead husband everywhere I go. C. The IRS may audit my taxes. D. Im not going to eat my food. It smells like brimstone.

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 persons intelligence or cultural background.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? A. Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness. B. When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. C. People with dissociative disorders typically have strong egos. D. There is clear and convincing evidence of a familial predisposition to this disorder.

A The nurse should understand that from a psychoanalytical perspective, dissociation occurs because of repression of painful information or experiences.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. What term should a nurse use when describing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior? A. Falling out in the African American culture B. Body rocking in the Vietnamese American culture C. Conversion disorder in the Jewish American culture D. Spirit possession in the Native American culture

A The nurse should use the term falling out to describe a sudden physical collapse and paralysis. This behavior is associated with the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 29. Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2,500 to 3,000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1,500 mL per day.

A, B, C The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents

D An adolescent raised by Scandinavian immigrant parents would be least prone to developing problems with anger and aggression as compared with the other clients presented. A history of abuse, epilepsy, overcrowding, and poverty all contribute as predisposing factors to anger and aggression.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 12. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement

D Anger can lead to aggression when the coping response is displacement. This client has discharged anger against a person (the nurse) unrelated to the true target of the anger (the spouse).

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 25. Which client statement would demonstrate a common characteristic of Cluster B personality disorder? A. I wish someone would make that decision for me. B. I built this building by using materials from outer space. C. Im afraid to go to group because it is crowded with people. D. I didnt have the money for the ring, so I just took it.

D Antisocial personality disorder is included in the Cluster B personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

D Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 8. The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

D Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

1. A highly agitated client paces the unit and states, I could buy and sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior? A. Rates mood 8/10. Exhibiting looseness of association. Euphoric. B. Mood euthymic. Exhibiting magical thinking. Restless. C. Mood labile. Exhibiting delusions of reference. Hyperactive. D. Agitated and pacing. Exhibiting grandiosity. Mood labile.

D The nurse should document that this clients behavior is Agitated and pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self- harm. The client refuses to commit to developing a plan for safety. What should be the nurses priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide

C The nurses priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. Youve really been helpful. Can I count on you for continued support? B. I dont work out anymore. C. Im really glad I didnt go home. It would have been hard to come back. D. I carry mace when I jog. It makes me feel safe and secure.

D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.

C A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be at risk for suicide.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 28. A nurse would expect a client diagnosed with schizotypal personality disorder to exhibit which characteristic? A. The client has many friends and associates but prefers to interact in small groups. B. The client has many brief but intense relationships. C. The client experiences incorrect interpretations of external events. D. The client exhibits lack of tender feelings toward others.

C Clients who are diagnosed with schizotypal personality disorder experience odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms. This results in incorrect interpretations of external events.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Safe and Effective Care Environment 18. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each clients belief system, the nurse should conclude which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

C Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 20. Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out? A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Reflecting back to the client empathy about the clients distress D. Presenting appropriate values that need to be modified

C Reflecting back to the client empathy about the clients distress promotes a trusting relationship and may prevent the clients anxiety from escalating when limits are set.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 8. The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurses assessment? A. The clients spouse died 12 months ago. B. The client still cries when recalling memories of the deceased. C. The client reports feelings of worthlessness. D. The client reports intermittent anxiety.

C Several authors identify loss of self-esteem as the differentiating factor between normal and maladaptive grieving. The length of time needed to grieve is variable, so it is difficult to establish a time frame as indicative of maladaptive grief.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. A nursing student asks an emergency department nurse, Why does a rapist use a weapon during the act of rape? Which nursing reply is most accurate? A. A weapon is used to increase the victimizers security. B. A weapon is used to inflict physical harm. C. A weapon is used to terrorize and subdue the victim. D. A weapon is used to mirror learned family behavior patterns.

C The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 12. A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should a nurse recognize? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction

C The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 23. The nurse plans to confront a client about secondary gains related to extreme dependency on her spouse. Which nursing statement would be most appropriate? A. Do you believe dependency issues have been a lifelong concern for you? B. Have you noticed any anxiety during times when your husband makes decisions? C. What do you know about individuals who depend on others for direction? D. How have the specifics of your relationship with your spouse benefited you?

D When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that they might not otherwise receive.

Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Psychosocial Integrity 20. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed.

C The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious and formal and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

Cognitive Level: Comprehension | Integrated Process: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 30. Laboratory results reveal elevated levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, the nurse should expect to observe which symptoms? Select all that apply. A. Apathy B. Social withdrawal C. Anhedonia D. Galactorrhea E. Gynecomastia

D, E Dopamine blockage, an expected action of antipsychotic medications, also results in prolactin elevation. Galactorrhea and gynecomastia are symptoms of prolactin elevation.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 19. A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the clients 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

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.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A client who is admitted to the inpatient psychiatric unit and is taking Thorazine presents to the nurse with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5C). The nurse identifies these symptoms as which of the following conditions? A. Neuroleptic malignant syndrome B. Tardive dyskinesia C. Acute dystonia D. Agranulocytosis

A Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 24. A client diagnosed with bipolar disorder states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. What should be the priority nursing action? A. Assess the clients vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.

A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The clients statement of Im thirsty and Im burning up could be a symptom of either infection or dehydration and must be assessed.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 30. Which nursing statement reflects a common characteristic of a client diagnosed with paranoid personality disorder? A. This client consistently criticizes care and has difficulty getting along with others. B. This client is shy and fades into the background. C. This client expects special treatment, and setting limits will be necessary. D. This client is expressive during group and is very pleased with self.

A A client diagnosed with paranoid personality disorder has a pervasive distrust and suspiciousness of others. Anticipating humiliation and betrayal, the paranoid individual characteristically learns to attack first.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 15. A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, You cant do this to me. Do you know who I am? Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation

A During a manic episode the clients mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. I am sad most of the time and Ive felt this way for the last several years. B. I find myself preoccupied with death. C. Sometimes I hear voices telling me to kill myself. D. Im afraid to leave the house.

A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity 4. 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, a nurse should recognize the continued need for which critical intervention? A. Suicide assessment must continue throughout the ECT course. B. Antidepressant medications are contraindicated throughout the ECT course. C. Discourage expressions of hopelessness throughout the ECT course. D. Encourage a high-caloric diet throughout the ECT course.

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 6. Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, Im not hungry and just want to stay in bed and sleep. On the basis of 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 physicians order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation.

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 15. A client begins to smash furniture, cannot be talked down, and refuses medications. Which is the most appropriate nursing intervention? A. Call a violence code. B. Ask the ward clerk to put in a call for the physician. C. Place the client in seclusion. D. Place the client in four-point restraints.

A In this situation the nurse must have adequate, trained help to prevent injury to the client or staff. Calling a violence code will access this help.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 24. A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? A. Assessing the clients pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurseclient relationship

A It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslows hierarchy of needs. This clients problems with oxygenation will take priority over assessing for current suicidal ideations.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 24. A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

A A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 15. 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

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action? A. The nurse notifies the clients physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room. C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the clients fluid intake to facilitate the digestive process.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this clients plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the clients laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes? A. Provide external limits on client behavior. B. Foster discussions of rationales for behavioral change. C. Implement interventions consistently by only one staff member. D. Encourage the client to involve self in care.

A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client? A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers

A Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 27. Which characteristics should a nurse recognize as being exhibited by individuals diagnosed with any personality disorder? A. These clients accept and are comfortable with their altered behaviors. B. These clients understand that their altered behaviors result from anxiety. C. These clients seek treatment to avoid interpersonal discomfort. D. These clients avoid relationships due to past negative experiences.

A Clients who are diagnosed with personality disorders accept and are comfortable with their altered behaviors. Personalities that develop in a disordered pattern remain somewhat unstable and unpredictable throughout the lifetime.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 12. A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, Im going to use a knotted shower curtain when no one is around. Which information would determine the nurses plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide.

A Clients who have specific plans are at greater risk for suicide.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 6. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathetic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to societal norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains

A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. Which client statement demonstrates improvement in anger/aggression management? A. I realize I have a problem expressing my anger appropriately. B. I know I cant use physical force anymore, but I can intimidate someone with my words. C. Its bad to feel as angry as I feel. Im working on eliminating this poisonous emotion entirely. D. Because my wife seems to be the one to set me off, Ive decided to remain separated from her.

A The client is recognizing and taking responsibility for personal anger.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? A. I know that it was not my fault. B. My boyfriend has trouble controlling his sexual urges. C. If I dont put myself in a dating situation, I wont be at risk. D. Next time I will think twice about wearing a sexy dress.

A The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self- worth.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. The family of a client diagnosed with conversion disorder asks the nurse, Will his paralysis ever go away? Which of these responses by the nurse is evidence-based? A. Most symptoms of conversion disorder resolve within a few weeks. B. Typically people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives. C. The only people who recover are those that develop conversion disorder symptoms without a precipitating stressful event. D. Technically, he could walk now since he is intentionally feigning paralysis.

A The evidence supports that most conversion disorder symptoms resolve within a few weeks, and about 20% will have a relapse within 1 year.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence? A. Power and control are central to the dynamic of domestic violence. B. Poor communication and social isolation are central to the dynamic of domestic violence. C. Erratic relationships and vulnerability are central to the dynamic of domestic violence. D. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

A The nurse accurately states that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 3. A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how should a nurse expect the neighbors action to affect the womans grieving task completion? A. This action may hamper the woman from accepting the reality of the loss. B. This action would help the woman forget the sorrow and move on with life. C. This action communicates full support from her neighbors. D. This action would motivate the woman to look to the future and not the past.

A The nurse should anticipate that this action could hinder the woman from accepting the reality of the loss. The first task in Wordens grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one so as not to have to face reality. The bereaved person is considered an active participant in the grief process and the above-mentioned behaviors are part of that process.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client? A. Deal with physical symptoms in a detached manner. B. Challenge the validity of physical symptoms. C. Meet dependency needs until the physical limitations subside. D. Encourage a discussion of feelings about the lower-extremity problem.

A The nurse should assist the client in dealing with physical symptoms in a detached manner to avoid reinforcing the symptoms by providing secondary gains. This is an example of a conversion disorder in which symptoms affect voluntary motor or sensory functioning. Examples include paralysis, aphonia, seizures, coordination disturbance, difficulty swallowing, urinary retention, akinesia, blindness, deafness, double vision, anosmia, and hallucinations.

A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the childs face and arms. What other symptom should indicate to the nurse that the child might have been physically abused? A. The child shrinks at the approach of adults. B. The child begs or steals food or money. C. The child is frequently absent from school. D. The child is delayed in physical and emotional development.

A The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns might be a victim of abuse. Whether or not the adult intended to harm the child, maltreatment should be considered.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 9. Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. B. Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, whereas clients diagnosed with avoidant personality disorder do not. C. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. D. Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, whereas clients diagnosed with avoidant personality disorder remain based in reality.

A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection, which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 22. 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

A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considered 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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients 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 childs hallucinations are caused by medication interactions. C. Your child has too little serotonin in the brain, causing delusions and hallucinations. D. Your childs abnormal hormonal changes have precipitated auditory hallucinations.

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.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 5. After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. Are you currently thinking about harming yourself? B. Why do you want to harm yourself? C. Have you thought about the consequences of your actions? D. Who is your emergency contact person?

A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential 21. 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

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 2. 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-Fowlers position to promote oxygenation C. In Trendelenburgs position to promote blood flow to vital organs D. In prone position to prevent airway blockage

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week? A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

A The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 7. A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is needed? A. In this culture, the color red is associated with death and is considered bad luck. B. In this culture, there is an innate fear of death. C. In this culture, emotions are not expressed openly. D. In this culture, death and bereavement are centered on ancestor worship.

A The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck. Chinese Americans consider the color white as associated with death and both the colors black and white are considered bad luck. Red is the ultimate color of luck in this culture. Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 20. A client who has been diagnosed with bipolar I disorder states, God has taught me how to decode the Bible. A nurse should anticipate that which combination of medications would be ordered to address this clients symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal)

A The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. A nurse is working with a client diagnosed with somatic symptom disorder. What predominant symptoms should a nurse expect to assess? A. Disproportionate and persistent thoughts about the seriousness of ones symptoms B. Amnestic episodes in which the client is pain free C. Excessive time spent discussing psychosocial stressors D. Lack of physical symptoms

A The primary focus in somatic symptom disorder is on physical symptoms that suggest medical disease but which have no basis in organic pathology. Although the symptoms are associated with psychosocial distress, the individual focuses on the seriousness of the physical symptoms rather than the underlying psychosocial issues.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others

A The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment: Management of Care 4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment

A The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.

Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment 19. Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, Do you ever think about killing yourself? B. Ask client, Please rate your mood on a scale from 1 to 10. C. Establish a trusting nurseclient relationship. D. Apply the nursing process to the planning of client care.

A The risk of suicide is greatly increased if the client has suicidal ideations, if the client has developed a plan, and particularly if the means exist for the client to execute the plan.

Cognitive Level: Applications | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 16. Which of the following nursing diagnoses would be expected for an adult survivor of incest?Select all that apply. A. Low self-esteem B. Powerlessness C. Disturbed personal identity D. Knowledge deficit E. Noncompliance

A, B An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders. Disturbed personal identity refers to an inability to distinguish between self and nonself and is seen in disorders such as autistic disorders, borderline personality disorders, dissociative disorders, and gender identity disorders.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 30. Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age. D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant.

A, B It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment Multiple Response 17. A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply. A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 11. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply. A. Tell me what happened. B. What coping methods have you used, and did they work? C. Describe to me what your life was like before this happened. D. Lets focus on the current problem. E. Ill assist you in selecting functional coping strategies.

A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment Multiple Response 25. After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply. A. I cant believe this is happening. B. If only I had been more understanding. C. How dare he do this to me! D. Im just going to have to accept that he was gay. E. Well, that was a selfish thing to do.

A, B, C Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father. The last two possible responses suggest acceptance and understanding. It is far more common for survivors of suicide to have a sense of feeling wounded and as if they will never get over it.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity Multiple Response 33. Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? Select all that apply. A. The client will relate one empathetic statement toward another client in group, by day 2. B. The client will identify one personal limitation by day 1. C. The client will acknowledge one strength that another client possesses by day 2. D. The client will list four personal strengths by day 3. E. The client will list two lifetime achievements by discharge.

A, B, C The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. An exaggerated sense of self-worth, a lack of empathy, and exploitation of others are characteristics of narcissistic personality disorder.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 19. During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply. Test Bank - Psychiatric Mental Health Nursing by Mary Townsend (9th Edition, 2017) 160 A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance 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

A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is 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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 30. A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. Ill have to let my surgeon know about this medication before I have my cholecystectomy. B. Guess I will have to give up my glass of red wine with dinner. C. Ill have to be very careful about reading food and medication labels. D. Im going to miss my caffeinated coffee in the morning. E. Ill be sure not to stop this medication abruptly.

A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions.

Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity 20. Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply. A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply. A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid I statements related to expression of feelings.

A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the clients anger. 1. A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, How will we know if someone may get violent? Which is the most appropriate reply by the nursing instructor? A. You cant really say for sure. There are limited indicators of potential violence. B. Certain behaviors indicate a potential for violence. They are labeled as a prodromal syndrome and include rigid posture, clenched fists, and raised voice. C. Any client can become violent, so it is best to be aware of your surroundings at all times. D. When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence. ANS: B These behaviors have been identified as predictors of violent behavior.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 15. When planning care for women in abusive relationships, which of the following information is important for the nurse to consider? Select all that apply. A. It often takes several attempts before a woman leaves an abusive situation. B. Substance abuse is a common factor in abusive relationships. C. Until children reach school age, they are usually not affected by parental discord. D. Women in abusive relationships usually feel isolated and unsupported. E. Economic factors rarely play a role in the decision to stay in abusive relationships.

A, B, D When planning care for women who have been victims of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victims decision to stay.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 18. Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply. A. Electrocardiographic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results

A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the clients physician. The client must be medically cleared prior to ECT.

Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity Multiple Response 11. A nurse is leading a bereavement group. Which of the following group members should the nurse identify as being at high risk for having difficulty grieving? Select all that apply. A. A widower who has recently experienced the death of two good friends B. A man whose wife died suddenly after a cerebrovascular accident C. A widow who, after a year, allowed removal of life support from her terminally ill husband D. A woman who had a competitive relationship with her recently deceased brother E. A young couple whose child recently died of a genetic disorder

A, B, D, E Several factors have been identified that may make the grief response more difficult: grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individuals physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. A widow who has experienced the process of loss for an extended period of time is more likely in the stage of acceptance and resolution of grief.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity Multiple Response 28. 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

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 28. A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

A, C, D Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post- menses

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 12. An instructor is teaching nursing students about Wordens grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? Select all that apply. A. Refusing to allow self to think painful thoughts B. Indulging in the pain of loss C. Using alcohol and drugs D. Idealizing the object of loss E. Recognizing that time will heal

A, C, D The nurse should identify that refusing to allow self to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Wordens grief process is working through the pain or grief. Pain must be acknowledged and resolved in order to move on.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply. A. In the Middle Ages, suicide was viewed as a selfish and criminal act. B. During the Roman Empire, suicide was followed by incineration of the body. C. Suicide was an offense in ancient Greece, and a common-site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically. E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

A, C, D These are true historical facts about suicide and should be included in the students study guide.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 34. A nurse is caring for a group of clients within theDSM-5 Cluster B category of personality disorders. Which factors should the nurse consider when planning client care? Select all that apply. A. These clients have personality traits that are deeply ingrained and difficult to modify. B. These clients need medications to treat the underlying physiological pathology. C. These clients use manipulation, making the implementation of treatment problematic. D. These clients have poor impulse control that hinders compliance with a plan of care. E. These clients commonly have secondary diagnoses of substance abuse and depression.

A, C, D, E The nurse should consider that individuals diagnosed with cluster Btype personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. A client is exhibiting symptoms of generalized amnesia. Which of the following questions should the nurse ask to confirm this diagnosis? Select all that apply. A. Can you tell me your name and where you live? B. Have you ever traveled suddenly or unexpectedly away from home? C. Have you recently experienced any traumatic event? D. Have you ever felt detached from your environment? E. Have you had any history of memory problems?

A, C, E An individual who has generalized amnesia has amnesia for his or her identity and total life history. The first question assesses orientation to identity. Items C and D assess for awareness of current issues and historical issues, respectively. Affirmative descriptions of either of these issues would rule out generalized amnesia.

Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Health Promotion and Maintenance Multiple Response 13. A client is diagnosed with illness anxiety disorder. Which of the following symptoms is the client most likely to exhibit? Select all that apply. A. Obsessive-compulsive traits B. Pseudocyesis C. Disabling fear of having a serious illness D. Multiple pronounced physical symptoms E. Depression

A, C, E Illness anxiety disorder involves a preoccupation with and fear of having or acquiring a serious disease. Somatic symptoms are either absent or mild in intensity.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 29. 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

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.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 13. Which of the following types of care should the interdisciplinary team of hospice provide?Select all that apply. A. Physical care available on a 24/7 basis B. Counseling on the addictive properties of pain-management medications C. Discussions related to death and dying D. Explorations of new, aggressive treatments E. Assistance with obtaining spiritual support and guidance

A, C, E The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying. Support is also provided to client families.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 22. A nurse notices a client clenching fists periodically and pacing the hallway. Which of the following nursing interventions would best assist the client at this time? Select all that apply. A. Acknowledge the clients behavior. B. Initiate forced medication protocol. C. Assist the client to a quiet area. D. Initiate confinement measures. E. Speak with a soft and calming voice.

A, C, E The nurse should remain calm when dealing with an angry client. It is important to acknowledge the clients behavior and assist the client to a less stimulating environment.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 15. Which of the following somatic symptom and dissociative disorders are identified with known effective pharmacological treatments for that disorder? Select all that apply. A. Antidepressants have been used effectively in treating pain associated with somatic symptom disorder. B. Lithium has been effective in treating illness anxiety disorder. C. Muscle relaxants have been effective in resolving conversion disorder symptoms. D. The antidepressant clomipramine (Anafranil) has shown promise in treating depersonalization-derealization disorder.

A, D The nurse should recognize that psychological therapies are central treatment modalities for these disorders, although evidence exists that for specific issues (as those identified in items A and C), psychopharmacological agents have demonstrated effectiveness.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity 12. A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the clients 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.

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. Well go to the day room when you are ready for group. B. Ill walk with you to the day room. Group is about to start. C. It must be difficult for you to attend group when you feel so bad. D. Let me tell you about the benefits of attending this group.

B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Psychosocial Integrity 22. Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. I will limit my intake of fluids daily. B. I will maintain normal salt intake. C. I will take Lithobid on an empty stomach. D. I will increase my caloric intake to prevent weight loss.

B A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 13. Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter

B A prior history of assault is the most widely recognized risk factor for client violence.

Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

B Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship.

B Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, and measureable and contain a time frame.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 9. A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? A. Your grieving will subside within 1 year; until then I recommend antidepressants. B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area. C. The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them. D. Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone.

B Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. Support groups for survivors can provide a meaningful resource for grief work.

Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. I cannot drink any alcohol with this medication. B. It is going to take 2 to 3 weeks in order for me to begin to feel better. C. This drug causes physical dependence, and I need to strictly follow doctors orders. D. I cant take this medication with food. It needs to be taken on an empty stomach.

B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 27. A newly admitted client diagnosed with major depressive disorder states, I have never considered suicide. Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. There is nothing to worry about. We will handle it together. B. Bringing this up is a very positive action on your part. C. We need to talk about the things you have to live for. D. I think you should consider all your options prior to taking this action.

B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 32. A client diagnosed with Cluster C traits sits alone and ignores others attempts to converse. When ask to join a group the client states, No, thanks. In this situation, which should the nurse assign as an initial nursing diagnosis? A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues

B Clients diagnosed with Cluster C traits are described as anxious and fearful. The DSM-5 divides Cluster C personality disorders into three categories: avoidant, dependent, and obsessive-compulsive. Anxiety and fear contribute to social isolation.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 25. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability

B Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 29. While improving, a client demands to have a phone installed in the intensive care unit (ICU) room. When a nurse states, This is not allowed; it is a unit rule, the client angrily demands to see the doctor. Which approach should the nurse use in this situation? A. Provide an explanation for the necessity of the unit rule. B. Assist the client to discuss anger and frustrations. C. Call the physician and relay the request. D. Arrange for a phone to be installed in the clients unit room.

B Clients who demand special privileges may be diagnosed with narcissistic personality disorder. The best approach in this situation is for the nurse to identify the function that anger, frustration, and rage serve for the client. The verbalization of feelings may help the client to gain insight into his or her behavior.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 15. A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

B Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

Cognitive Level: Application | Integrated Process: Nursing Process: Planning | Client Need: Psychosocial Integrity 9. Which of the following statements accurately describes dissociative fugue? A. Dissociative fugue is not precipitated by stressful events. B. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of ones past. C. Dissociative amnesia and dissociative fugue are completely different types of disorders. D. Dissociative fugue is characterized by a sense of observing oneself from outside the body.

B Dissociative fugue is characterized by unexpected travel or bewildered wandering, and amnesia for all or part of ones past. Dissociative fugue is a subtype of dissociative amnesia.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 18. The nurse observes a clients escalating anger. The client begins to pace the hall and shouts, You all better watch out. Im going to hurt anyone who gets in my way. Which should be the priority nursing intervention? A. Calmly tell the client, Staff will help you to control your impulse to hurt others. B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, You will need to be medicated and secluded.

B During an emergent situation on an inpatient unit, the nurses priority action should be to keep all clients safe by removing them from the area of conflict.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 8. A despondent client, who has recently lost her husband of 30 years, tearfully states, Ill feel a lot better if I sell my house and move away. Which nursing reply is most appropriate? A. Im confident you know whats best for you. B. This may not be the best time for you to make such an important decision. C. Your children will be terribly disappointed. D. Tell me why you want to make this change.

B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 3. 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.

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.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 27. A clients spouse asks, What evidence supports the possibility of genetic transmission of bipolar disorder? Which is the best nursing reply? A. Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors. B. Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder. C. Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress. D. More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds.

B Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 2. A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. Anger is physiological arousal. B. Anger and aggression are essentially the same. C. Anger expression is a learned response. D. Anger is not a primary emotion.

B Further teaching is necessary when the student states that anger and aggression are essentially the same. Anger and aggression are significantly different.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. I cant stop my sexual urges. They have led me to numerous affairs. B. Im the worlds most perceptive attorney. C. My wife is distraught about my overspending. D. The FBI is out to get me.

B Grandiosity is defined as a belief that personal abilities are better than anyone elses. This client is experiencing delusions of grandeur, which are commonly experienced in mania.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 21. Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? A. Place a hand on the clients shoulder and state, I will help you to your room. B. Slowly and matter-of-factly state, I am your nurse and I will show you to your room. C. Firmly set limits by stating, If your behavior does not improve you will be secluded. D. Smile and state, I am your nurse. When do you want to go to your room?

B It is important to maintain an unemotional tone of voice when dealing with a hostile client. The client might misinterpret touch and become violent.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 9. Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards? A. The patient must be let out of restraint. B. A physician or other licensed independent practitioner must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing.

B Joint Commission (JCAHO) standards require that a physician or other licensed independent practitioner conduct an in-person evaluation of the client within 1 hour of the initiation of restraint.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 26. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 24. The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis.

B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 13. 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 undergo 6 to 12 ECT procedures, three times a week in an outpatient setting. C. Clients typically receive an unlimited number of treatments, in the hospital procedure room. D. Clients typically receive two to three treatments, in either an outpatient or inpatient setting.

B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures. 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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of suffering in silence. Which underlying cause of this clients personality disorder should a nurse recognize? A. Nurturance was provided from many sources, and independent behaviors were encouraged. B. Nurturance was provided exclusively from one source, and independent behaviors were discouraged. C. Nurturance was provided exclusively from one source, and independent behaviors were encouraged. D. Nurturance was provided from many sources, and independent behaviors were discouraged.

B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, Im feeling a lot better, so you can stop watching me. I have taken up too much of your time already. Which is the best nursing reply? A. I really appreciate your concern but I have been ordered to continue to watch you. B. Because we are concerned about your safety, we will continue to observe you. C. I am glad you are feeling better. The treatment team will consider your request. D. I will forward you request to your psychiatrist because it is his decision.

B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. Which is the most accurate description of the nursing diagnosis of spiritual distress? A. The client reports no church affiliations. B. The client struggles to identify meaning and purpose in life. C. The client reports seeing the spirit of his deceased wife. D. The client reports that meditation helps him feel connected spiritually.

B One common nursing diagnosis in relation to complicated grief (and some authors would argue that all grief is complicated) is the risk for spiritual distress, which addresses the persons sense of meaning, purpose, and outlook for the future.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 10. For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions.

B Restraints are used for clients who are unable to control their behavior in order to prevent harming themselves or others.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 10. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool

B The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the clients restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order

B The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children.

1. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. You are very disrespectful. You need to learn to control yourself. B. I understand that you are angry, but this behavior will not be tolerated. C. What behaviors could you modify to improve this situation? D. What anti-personality-disorder medications have helped you in the past?

B The appropriate nursing statement is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the treatment of a personality disorder.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess? A. The client expresses feeling blue most of the time. B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.

B The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder.

Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 14. A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. Administering psychotropic medications can be a part of violence-intervention protocols. B. Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols. C. Applying leather restraints can be a part of violence-intervention protocols. D. Calling for assistance is a part of violence-intervention protocols.

B Touching the client could be seen by him or her as threatening and provoke further violence.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 5. A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this clients safety upon discharge? A. Provide a 6-month supply of Elavil to ensure long-term compliance. B. Provide a 1-week supply of Elavil with refills contingent on follow-up appointments. C. Provide a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.

B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the clients safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 17. After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement? A. I should expect to feel better in a couple of days. B. Ill call my doctor immediately if I experience any diarrhea or ringing in my ears. C. If I forget a dose, I can double the dose the next time I take this drug. D. I need to restrict my intake of any food containing salt.

B The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. C. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. D. They pay particular attention to details, which can frustrate the development of relationships.

B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.

Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Psychosocial Integrity 4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the event, as this may lead to further emotional trauma. B. Remain nonjudgmental and actively listen to the clients description of the event. C. Meet the clients self-care needs by assisting with showering and perineal care. D. Provide cues, based on police information, to encourage further description of the event.

B The most appropriate nursing action is to remain nonjudgmental and actively listen to the clients description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care 16. Using a behavioral approach, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues.

B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment 14. A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. 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.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 11. 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.

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 clients needs and maintain a calm attitude when dealing with agitated behavior.

Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Psychosocial Integrity 7. 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

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 clients 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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 22. Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge? A. I must observe you continually for 1 hour in order to keep you safe. B. Lets confer with the treatment team about the resources that you may need after discharge. C. You must have been very upset to do what you did today. D. Are you currently thinking about harming yourself?

B The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss client problems and needs.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 2. A nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, Im planning an elaborate wake and funeral. According to George Engel, what purpose would these rituals serve? A. To delay the recovery process initiated by the loss of the clients spouse B. To facilitate the acceptance of the loss of the clients spouse C. To avoid dealing with grief associated with the loss of the clients spouse D. To eliminate emotional pain related to the loss of the clients spouse

B The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the clients spouse. Resolution of the loss is the fourth stage in Engels grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 9. An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers.

B The nurse should assess that tense facial expressions and body language may indicate that a clients anger is escalating. The nurse should conduct a thorough assessment of the clients past and current violent behaviors and develop interventions for de-escalation.

1. A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kbler-Rosss grief stage of anger? A. The client registers for an iron-man marathon to be held in 9 months. B. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him. C. The client promises God to give up smoking if allowed to live long enough to witness a grandchilds birth. D. The client gathers family in order to plan a funeral and make last wishes known.

B The nurse should assess that the client is in the anger stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kbler-Rosss grief process, in which the reality of the situation is realized and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. 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 clients statement? A. The client is experiencing command hallucinations. B. The client is expressing a neologism. C. The client is experiencing a paranoia. D. The client is verbalizing a word salad.

B The nurse should describe the clients 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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 3. Which would be considered an appropriate outcome when planning care for an inpatient client diagnosed with somatic symptom disorder? A. The client will admit to fabricating physical symptoms to gain benefits by day 3. B. The client will list three potential adaptive coping strategies to deal with stress by day 2. C. The client will comply with medical treatments for physical symptoms by day 3. D. The client will openly discuss physical symptoms with staff by day 4.

B The nurse should determine that an appropriate outcome for a client diagnosed with somatic symptom disorder would be for the client to list three potential adaptive coping strategies to deal with stress by day 2. Because the symptoms of somatic symptom disorder are associated with psychosocial distress, increasing coping skills may help the client reduce symptoms.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, I cant function any longer under all this stress. Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis

B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 13. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body

B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 21. Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder

B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor add that to my medications? Which is an appropriate nursing reply? A. This combination of drugs can lead to delirium tremens. B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis. C. Thats a good idea. There have been good results with the combination of these two drugs. D. The only disadvantage would be the exorbitant cost of the MAOI.

B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 25. A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the clients 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

B The nurse should focus on the clients feelings rather than attempt to change the clients 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.

Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. Which grieving behaviors should a nurse anticipate when caring for a Southwest Navajo Indian client? A. Celebrating the life of a deceased person with festivities and revelry B. Not expressing grief openly and reluctance to touch a dead body C. Holding a prayerful vigil for a week following the persons death D. Expressing grief openly and publicly and erecting an altar in the home to honor the dead

B The nurse should identify that a Navajo client would not express grief openly and would be reluctant to touch a dead body. Navajo Indians do not bury the body of a deceased person for 4 days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers.

Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment 2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

B The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.

1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients 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

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 16. A nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the clients positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 14. An anorexic client states to a nurse, My father has recently moved back to town. Since that time the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated and lives alone. What should the nurse suspect? A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood bulimia

B The nurse should suspect that this client might have a history of childhood incest. Adult survivors of incest are at risk for developing posttraumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 24. A college student has quit attending classes, isolates self because of 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

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesperson to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership.

B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 8. A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred? A. This disorder is more prevalent in the lower socioeconomic groups. B. This disorder is more prevalent in the higher socioeconomic groups. C. This disorder is equally prevalent in all socioeconomic groups. D. This disorders prevalence cannot be evaluated on the basis of socioeconomic groups.

B The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 18. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L

B The therapeutic level of lithium carbonate is 1.0 to 1.5 mEq/L for acute mania and 0.6 to 1.2 mEq/L for maintenance therapy. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7 mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 10. After years of dialysis, an 84-year-old states, Im exhausted, depressed, and done with these attempts to keep me alive. Which question should the nurse ask the spouse when preparing a discharge plan of care? A. Have there been any changes in appetite or sleep? B. How often is your spouse left alone? C. Has your spouse been following a diet and exercise program consistently? D. How would you characterize your relationship with your spouse?

B This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. Although the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death among the elderly. D. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

B This factual information should be included in the nursing instructors teaching plan. An expressed desire to die is not normal in any age group.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 7. An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary? A. I hate all of you! B. My fingers are tingly. C. You wait until I tell my lawyer. D. I have a sinus headache.

B This statement may mean that the restraints are excessively tight and impeding circulation.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment 12. At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation? A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the clients case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist

B To meet Joint Commission standards, an in-person evaluation by a physician or LIP should be conducted within 1 hour of the initiation of restraints.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 29. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the clients symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 16. 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 impact 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 could could preclude this option D. Because of the clients cognitive deficits, a signed consent is waived.

C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the clients level of competency and, if necessary, the judge would appoint a guardian.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 21. Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

C A degree of the responsibility for the suicidal clients safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 23. A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide? A. Family history of depression B. The clients orientation to reality C. The clients history of suicide attempts D. Family support systems

C A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the clients risk.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimers disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security

C A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 27. A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia 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.

C Altered thinking can affect a clients 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.

Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. Which should the nurse recognize as an example of localized amnesia? A. A client cannot relate any lifetime memories, including personal identity. B. A client can relate family memories but has no recollection of a particular brother. C. A client cannot remember events surrounding a fatal car accident. D. A client whose home was destroyed by a tornado only remembers waking up in the hospital.

C An individual with localized amnesia is unable to recall all incidents associated with a stressful event.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential 10. A client who is learning about electroconvulsive therapy (ECT) asks a nurse, Isnt 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 (TIAs) can occur but are rare.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurses initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.

C During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurses initial action should focus on removing the client from the stimulating environment to a calmer location.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 19. The client states, I get into trouble because I respond violently without thinking. That usually gets me into a mess. Which nursing reply would be most therapeutic to address this clients problem? A. Everybody loses their temper. Its good that you know that about yourself. B. Ill bet you have some interesting stories to share about overreacting. C. Lets explore methods to help you stop and think before taking action. D. Its good that you are showing readiness for behavioral change.

C Helping the client to find alternative ways to release tension by more appropriate problem-solving behaviors is a therapeutic nursing intervention.

Cognitive Level: Application | Integrated Process: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 8. A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). 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.

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

A client diagnosed with somatic symptom disorder is most likely to exhibit which personality disorder characteristics? A. Uses splitting and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange

C It has been suggested that in somatic symptom disorder, there may be some overlapping of personality characteristics and features associated with histrionic personality disorder. These features include heightened emotionality, impressionistic thought and speech, seductiveness, strong dependency needs, and a preoccupation with symptoms and oneself. Somatic symptom disorder is characterized by the expression of multiple somatic complaints associated with psychosocial distress and without medical basis.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 4. Carly has been diagnosed with somatic symptom disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? A. The family agrees that Carly began having physical symptoms after she lost her job. B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. C. Carlys mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. D. Carly states she noticed feeling hotter than usual the last time she had a headache.

C It is important for the nurse to identify gains that the symptoms might be providing for the client, since these can reinforce illness behavior. Having family attend to the patient when she is symptomatic could reinforce increased dependency and attention needs.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 26. 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 clients personality structure.

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this clients symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

C Learning theory describes a model of learned helplessness in which multiple life failures cause the client to abandon future attempts to succeed.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment 11. A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns Risk for other-directed violence as the clients priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift.

C Preventing injury to others is the appropriate outcome. Outcomes must be client centered, specific, realistic, and measureable and contain a time frame. Answer A does not contain a time frame.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

C Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse managers best reply? A. Suicide is a DSM-5 diagnosis. B. Suicide is a mental disorder. C. Suicide is a behavior. D. Suicide is an antisocial affliction.

C Suicide is not a diagnosis, disorder, or affliction. It is a behavior.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 5. After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, I cant even remember eating breakfast, so I want to stop the ECT. Which is the most appropriate nursing reply? A. After you begin the course of treatments, you must complete all of them. B. Youll need to talk with your doctor about what youre thinking. C. It is within your right to discontinue the treatments, but lets talk about your concerns. D. Memory loss is a rare side effect of the treatment. I dont think it should be a concern.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. When questioned about bruises, a woman states, It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it wont happen again. This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

C The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the clients paranoid perceptions.

C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A client diagnosed with schizophrenia states, Cant you hear him? Its the devil. Hes telling me Im 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. Im sure the voices sound scary. I dont hear any voices speaking. D. The devil only talks to people who are receptive to his influence.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, The beatings have been getting worse, and Im afraid that next time he might kill me. Which is the appropriate nursing reply? A. Leopards dont change their spots, and neither will he. B. There are things you can do to prevent him from losing control. C. Lets talk about your options so that you dont have to go home. D. Why dont we call the police so that they can confront your husband with his behavior?

C The most appropriate reply by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions independently without the nurse being the rescuer. Imposing judgments and giving advice is nontherapeutic.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 4. Parents ask a nurse how they should reply when their child, diagnosed with 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.

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. 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

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).

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 2. A client diagnosed with antisocial personality disorder comes to a nurses station at 11:00 p.m., requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. Go ahead and use the phone. I know this pending divorce is stressful. B. You know better than to break the rules. Im surprised at you. C. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow. D. The decision to divorce should not be considered until you have had a good nights sleep.

C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 20. An elderly client diagnosed with schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, the nurse would most appropriately make which statement? 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.

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.

Multiple Choice 1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurses 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

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.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 7. A client diagnosed with dissociative identity disorder (DID) switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? A. It is a means to attain secondary gain. B. It is a means to explore feelings of excessive and inappropriate guilt. C. It serves to isolate painful events so that the primary self is protected. D. It serves to establish personality boundaries and limit inappropriate impulses.

C The nurse should anticipate that a client who switches personalities when confronted with destructive behavior is dissociating in order to isolate painful events so that the primary self is protected. The transition between personalities is usually sudden, dramatic, and precipitated by stress.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 4. A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder

C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurses priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.

C The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self- destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 12. A client diagnosed with schizophrenia states, My psychiatrist is out to get me. Im sad that the voice is telling me to stop him. What symptom is the client exhibiting, and what is the nurses 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

C The nurse should determine that the client is exhibiting command hallucinations. The nurses 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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 10. What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger

C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being taken down after a violent outburst is to process feelings and concerns related to the witnessed intervention.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance 7. A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply? A. Thats strange. Weight loss is the typical pattern. B. What have you been eating? Weight gain is not usually associated with lithium. C. Weight gain is a common but troubling side effect. D. Weight gain occurs only during the first month of treatment with this drug.

C The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 19. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment

C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 9. A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process? A. Stage I: Numbness or protest B. Stage II: Disequilibrium C. Stage III: Disorganization and despair D. Stage IV: Reorganization

C The nurse should identify that this client is in the third stage of Bowlbys grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost individual may occur.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 18. Looking at a slightly bleeding paper cut, the client screams, Somebody help me, quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over-gregarious, and seductive.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 20. A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this clients risk for suicide? A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times

C The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity 3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3

C The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients physical and safety needs.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 2. 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

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 6. An inpatient client is newly diagnosed with dissociative identity disorder (DID) stemming from severe childhood sexual abuse. Which nursing intervention takes priority? A. Encourage exploration of sexual abuse B. Encourage guided imagery C. Establish trust and rapport D. Administer antianxiety medications

C The nurse should prioritize establishing trust and rapport when beginning to work with a client diagnosed with dissociative identity disorder. DID was formerly called multiple personality disorder. Each personality views itself as a separate entity and must be treated as such to establish rapport. Trust is the basis of every therapeutic relationship.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 9. A client diagnosed with brief psychotic disorder 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

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment: Management of Care 22. When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites

C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 1. A nurse discovers a clients suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note B. Establishing room restrictions, because the clients threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting, because the clients threat must be addressed

C The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations

C The priority nursing diagnosis for this client is Risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order? A. This dosage is within the recommended dosage range. B. This dosage is lower than the recommended dosage range. C. This dosage is more than twice the recommended dosage range. D. This dosage is four times higher than the recommended dosage range.

C The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 15. 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

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.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity 16. What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The clients understanding of the need for regular bloodwork B. The clients mood and affect score, according to the facilitys mood scale C. The clients cognitive ability to understand information about the medication D. The clients access to a support network willing to participate in treatment

C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. In the emergency department, a raped client appears calm and exhibits a blunt affect. The client answers a nurses questions in a monotone using single words. How should the nurse interpret this clients responses? A. The client may be lying about the incident. B. The client may be experiencing a silent rape reaction. C. The client may be demonstrating a controlled response pattern. D. The client may be having a compounded rape reaction.

C This client is most likely demonstrating a controlled response pattern. In a controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension.

Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Reduction of Risk Potential 11. A client experienced bradycardia during electroconvulsive therapy (ECT). 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.

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.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior.

D The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 26. The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom dcor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? A. Rooms should contain extra-large windows with views of the street. B. Rooms should contain brightly colored walls with printed drapes. C. Rooms should be painted deep colors and located close to the nurses station. D. Rooms should be painted with neutral colors and contain pale-colored accessories.

D Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the clients environment (low lighting, few people, simple dcor, low noise levels). Anxiety levels rise in a stimulating environment. Neutral colors and pale accessories are most appropriate for a client experiencing mania.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 8. After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the clients return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing

D Debriefing is an important part of restraint/seclusion. It allows the staff an opportunity to review and learn from the experience and to express feelings generated by the incident.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 31. A client exhibits dependency on staff and peers and expresses fear of abandonment. Using Mahlers theory of object relations, which should the nurse expect to note in this clients childhood? A. Lack of fulfillment of basic needs by parental figures B. Absence of the clients maternal figure during symbiosis C. Difficulty establishing trust with the maternal figure D. Inconsistency by the maternal figure during individuation

D During phase 3 (5 to 36 months) of Margaret Mahlers individuation theory, there should be a strengthening of the ego and an acceptance of self with independent ego boundaries. Inconsistency by the maternal figure during individuation may in later years result in feelings of helplessness when the client is alone because of exaggerated fears of being unable to care for self.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 7. A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 7. A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a clients electroconvulsive therapy (ECT) procedure. 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.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |Client Need: Psychosocial Integrity 21. Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. Its just a matter of time and I will be well. B. If I ignore these feelings, they will go away. C. I can fight these feelings and overcome this disorder. D. Nothing will help me feel better.

D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 25. A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity 17. A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? A. Suicidal threats and gestures should be considered manipulative and/or attention-seeking. B. Suicide is the act of a psychotic person. C. All suicidal individuals are mentally ill. D. Fifty to eighty percent of all people who kill themselves have a history of a previous attempt.

D It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt. All other answer choices are myths about suicide.

Cognitive Level: Application | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the teams decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

D Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours

D The Joint Commission (JCAHO) requires that a physician or licensed independent provider (LIP) must reissue a new order for restraints every 4 hours for adults, every 1 hour for clients younger than 9, and every 2 hours for clients 9 to 17 years.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 14. Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay. B. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you dont stay with me. C. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please dont go! I cant sleep without you being here. D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me.

D The clients statement I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.

Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment: Management of Care 6. During a one-to-one session with a client, the client states, Nothing will ever get better, and Nobody can help me. Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements

D The clients statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the clients suicidal ideations and intent would be necessary.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 10. Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia? 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 clients boundaries.

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

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 5. A nurse is assessing a client diagnosed with 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. Paranoia C. Magical thinking D. Delusions of reference

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 17. A client diagnosed with major depressive disorder states, Ive been feeling down for 3 months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients affective symptoms? A. Have you been diagnosed with any physical disorder within the last 3 months? B. Have you ever felt this way before? C. People who have mood changes often feel better when spring comes. D. Help me understand what you mean when you say, feeling down?

D The nurse is using a clarifying statement in order to gather more details related to this clients mood.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 8. A client is diagnosed with dissociative identity disorder (DID). What is the primary goal of therapy for this client? A. To recover memories and improve thinking patterns B. To prevent social isolation C. To decrease anxiety and need for secondary gain D. To collaborate among subpersonalities to improve functioning

D The nurse should anticipate that the primary therapeutic goal for a client diagnosed with DID is to collaborate among subpersonalities to improve functioning. Some clients choose to pursue a lengthy therapeutic regimen to achieve integration, a blending of all the personalities into one. The goal is to optimize the clients ability to function appropriately and achieve optimal personal potential.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity 3. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 10. During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. I really dont have a problem. My family is inflexible, and every relative is out to get me. B. I am so excited about working with you. Have you noticed my new nail polish, Ruby Red Roses? C. I spend all my time tending my bees. I know a whole lot of information about bees. D. I am getting a message from the beyond that we have been involved with each other in a previous life.

D The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 17. A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, 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, treated by discontinuing antipsychotic medications B. Agranulocytosis, treated by administration of clozapine (Clozaril) C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin) D. Tardive dyskinesia, treated by discontinuing antipsychotic medications

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions the Zyprexa order. Which is the appropriate nursing reply? A. Zyprexa in combination with Eskalith cures manic symptoms. B. Zyprexa prevents extrapyramidal side effects. C. Zyprexa ensures a good nights sleep. D. Zyprexa calms hyperactivity until the Eskalith takes effect.

D The nurse should explain to the clients spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity 17. A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? A. You really dont have to go by that schedule. Id just stay home sick. B. There has got to be a hidden agenda behind this schedule change. C. Who do you think you are? I expect to interact with the same nurse every Saturday. D. You cant make these kinds of changes! Isnt there a rule that governs this decision?

D The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity 3. A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this clients crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6.

D The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance 9. A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

D The nurse should interpret that the clients symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity 23. During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. On the basis of 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

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.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a safe house for battered women

D The nurse should provide information about safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear for their lives.

Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment 17. A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client.

D To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity 9. A confused client has recently been prescribed sertraline (Zoloft). The clients spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment 2. A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman might be a victim of incest.

D The nurse should suspect that this client might be a victim of incest. Women in abusive relationships often grew up in abusive homes.

1. A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.

Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 2. During the planning of care for a suicidal client, which correctly written outcome should be a nurses first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay.

D The nurses priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurses priority. The A answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, and realistic and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated.

Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. Treatment is compromised when clients cant sleep. B. Treatment is compromised when irritability interferes with social interactions. C. Treatment is compromised when clients have no insight into their problems. D. Treatment is compromised when clients choose not to take their medications.

D The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications. Symptoms of bipolar disorder will reemerge if medication is stopped.

Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, Why doesnt she just leave him? Which is the nursing supervisors most appropriate reply? A. These clients dont know life any other way, and change is not an option until they have improved insight. B. These clients have limited skills and few vocational abilities to be able to make it on their own. C. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation. D. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.

D The nursing supervisor is accurate when stating that clients in severely abusive relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner for some of the following reasons: for the children, financial reasons, fear of retaliation, lack of a support network, religious reasons, and/or hopelessness.

Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity 4. A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client? A. Denial of personal mortality B. Preoccupation with the loss C. Clinging behaviors and personal insecurity D. Acting-out behaviors, exhibited in aggression and defiance

D The school nurse should anticipate that this teenager would exhibit aggression and acting-out behaviors. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to express sorrow by acting out rather than typical emotional expressions of the grieving process.

Cognitive Level: Application | Integrated Processes: Assessment | Client Need: Safe and Effective 13. A suicidal client says to a nurse, Theres nothing to live for anymore. Which is the most appropriate nursing reply? A. Why dont you consider doing volunteer work in a homeless shelter? B. Lets discuss the negative aspects of your life. C. Things will look better in the morning. D. It sounds like you are feeling pretty hopeless.

D This statement verbalizes the clients implied feelings and allows him or her to validate and explore them.