Mental Health Exam 2
A nurse is providing teaching to a client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make? 1. "Feelings of sedation should resolve in about 1 week." 2. "There is no risk of physical dependence with this medication." 3. "You can increase the dose when you feel especially anxious." 4. "It will take several months for you to feel the maximum benefit of the medication."
1 Rationale: Adverse effects of diazepam and other benzodiazepines are sedation and psychomotor slowing. The nurse should inform the client that these effects should subside in 7 to 10 days.
A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective? 1. The client reports techniques she uses to promote sleep 2. The client shows limited emotion when witnessing a traumatic event 3. The client asks the nurse's opinion about the clothes she is wearing 4. The client avoids situations that might trigger memories of past trauma
1 Rationale: Clients who have PTSD often experience disrupted sleep; therefore, reporting the use of techniques that promote sleep indicates the current treatment plan is effective.
A nurse is caring for a client with schizophrenia who has been taking chlorpromazine for the past 2 months. Which of the following findings demonstrates that the chlorpromazine has been effective? 1. The client reports that hallucinations occur less frequently. 2. The client sleeps uninterrupted for 6 hr each night. 3. The client reports that she is the "most important person on the unit." 4. The client demonstrates stereotyped behaviors.
1 Rationale: The nurse should identify the chlorpromazine, when used to treat schizophrenia, reduces hallucinations. Chlorpromazine is a first-generation conventional antipsychotic medication and is effective in decreasing delusions, hallucinations, and agitation. It can also treat manic behavior in clients who have bipolar disorder.
Which of the following symptoms are seen when a client abruptly stops taking diazepam (Valium)? Select all that apply. 1. Insomnia 2. Tremors 3. Delirium 4. Dry mouth 5. Lethargy
1, 2, 3 Rationale: Insomnia, tremors, and delirium may be experienced if diazepam is abruptly stopped.
Which of the following medications can be used to treat clients with anxiety disorders? Select all that apply. 1. Clonidine hydrochloride (Catapres) 2. Fluvoxamine maleate (Luvox) 3. Buspirone (BuSpar) 4. Alprazolam (Xanax) 5. Haloperidol (Haldol)
1, 2, 3, 4 Rationale: Clonidine hydrochloride (Catapres), an antihypertensive, is used in the treatment of panic disorders and generalized anxiety disorder. Fluvoxamine maleate (Luvox), an antidepressant, is used in the treatment of obsessive-compulsive disorder. Buspirone (BuSpar), an anxiolytic, is used in the treatment of panic disorders and generalized anxiety disorders. Alprazolam (Xanax), a benzodiazepine, is used for the short-term treatment of anxiety-disorders.
Which of the following symptom assessments would validate the diagnosis of generalized anxiety disorder? Select all the apply. 1. Excessive worry about items difficult to control 2. Muscle tension 3. Hypersomnia 4. Excessive amounts of energy 5. Feeling "keyed up" or "on edge"
1, 2, 5 Rationale: A client diagnosed with GAD would experience excessive worry about items difficult to control, muscle tension, and an increased startle reflex and tension, causing feelings of being "keyed up" or being "on edge."
A client rates anxiety at 8/10 on a scale of 1 to 10, is restless, and has narrowed perceptions. Which of the following medications could be appropriately prescribed to address these symptoms? Select all that apply. 1. Chlordiazepoxide (Librium) 2. Clonazepam (Klonopin) 3. Lithium carbonate (Lithium) 4. Clozapine (Clozaril) 5. Oxazepam (Serax)
1, 2, 5 Rationale: Librium, Klonopin, and Serax are all benzodiazepines. Benzodiazepines are classified as antianxiety medications and would be appropriately prescribed to address signs and symptoms of anxiety.
Which of the following stimulant medications are prescribed in the treatment of ADHD? Select all that apply. 1. Methylphenidate (Concerta) 2. Guanfacine (Intuniv) 3. Lisdexamfetamine (Vyvanse) 4. Amphetamine/dextroamphetamine (Adderall) 5. Clonidine (Catapres)
1, 3, 4 Rationale: Concerta, Vyvanse, and Adderall are stimulant medications used in the treatment of ADHD.
A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as, "Me, see, bee, tree." The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia? 1. Clang association 2. Echolalia 3. Magical thinking 4. Word salad
1. Clang association Rationale: Stringing and repeating words together because of their rhyming sounds is called clang association. Clang association is a positive manifestation of schizophrenia.
A nurse is assessing a client with a long history of being a loner and having few social relationships. This client's father has been diagnosed with schizophrenia. The nurse would suspect that this client is in what phase of the development of schizophrenia? 1. Phase I- premorbid phase 2. Phase II- prodromal phase 3. Phase III- schizophrenia 4. Phase IV- residual phase
1. Phase I- premorbid phase Rationale: The premorbid personality often indicates social maladjustment, social withdrawal, irritability, and antagonist thoughts and behaviors. Behavioral measurements that have been noted include being very shy, and withdrawn, having poor peer relationships, and doing poorly in school.
A nurse is assessing a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? 1. Positive 2. Cognitive 3. Negative 4. Affective
1. Positive Rationale: The nurse should identify a client who has schizophrenia and is experiencing delusions is demonstrating a positive symptom. Positive symptoms are seen early in clients who have schizophrenia and are easier to detect than other types of symptoms. Other positive symptoms include hallucinations, disorganized speech, and disorganized behavior.
A nurse is caring for a client who has generalized anxiety disorder (GAD). Which of the following goals should the nurse include in the discharge plan of care for this client? 1. Use whistling or singing as a distraction to control hallucinations 2. Make independent decisions about daily events 3. Verbalize a realistic perception of personal appearance 4. Decrease the use of ritualistic behaviors
2 Rationale: A client who has GAD demonstrates indecisiveness and has unrealistic and persistent anxiety most days of the week. This can cause the client to avoid situations that produce anxiety or procrastinate necessary decision-making. The ability to make independent decisions about daily events is a goal the nurse should include in the discharge plan of care for the client.
Which teaching need is important when a client is newly prescribed buspirone (BuSpar) 5 mg tid? 1. Encourage the client to avoid drinking alcohol while taking this medication because of the additive central nervous system depressant effects. 2. Encourage the client to take the medication continuously as prescribed because the onset of action is delayed 2 to 3 weeks. 3. Encourage the client to monitor for signs and symptoms of anxiety to determine the need for additional buspirone (BuSpar) prn. 4. Encourage the client to be compliant with monthly lab tests to monitor for medication toxicity.
2 Rationale: It is important to teach the client that the onset of action for buspirone (BuSpar) is 2 to 3 weeks. Often the nurse may see a benzodiazepine, such a clonazepam (Klonopin), prescribed because of its quick onset of effect, until the buspirone begins working.
From a biochemical influence perspective, which accurately describes the etiology of schizophrenia? 1. Adopted children with nonschizophrenic parents, raised by parents diagnosed with schizophrenia, have a higher incidence of this disease 2. An excess of dopamine-dependent neuronal activity occurs in the brain 3. A higher incidence of schizophrenia occurs after there is prenatal exposure of the mother to influenza 4. Poor parent-child interaction and dysfunctional family systems occur
2 Rationale: The dopamine hypothesis suggests that schizophrenia may be caused by an excess of dopamine-dependent neuronal activity in the brain. This excess activity may be related to increased production, or release, of the substance at nerve terminals; increased receptor sensitivity; too many dopamine receptors; or a combination of these mechanisms. This etiological theory is from a biochemical influence perspective.
Although symptoms of schizophrenia occur at various times in the life span, what client would be more likely be diagnosed? 1. A 10-year old girl 2. A 20 year-old man 3. A 50 year-old woman 4. A 65 year-old man
2. A 20 year-old man Rationale: Symptoms of schizophrenia generally appear in late adolescence or early adulthood. Some studies have indicated that symptoms occur earlier in men than in women.
A client on an in-patient psychiatric unit refuses to take medications because "the pill has a special code written on it that will make it poisonous." What kind of delusion is this client experiencing? 1. An erotomanic delusion 2. A grandiose delusion 3. A persecutory delusion 4. A somatic delusion
3 Rationale: A persecutory delusion is a type of delusion in which the individual believes he or she is being malevolently being treated in some way. Frequent themes include being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. The situation described in the question reflects this type of delusion.
A client states to the nurse "I see headless people walking down the hall at night." Which nursing response is appropriate? 1. "What makes you think there are headless people here?" 2. "Let's think about this. A headless person would not be able to walk down the hall." 3. "It must be frightening, I realize this is real to you, but I see no headless people." 4. "I don't see those people you are talking about."
3 Rationale: Empathizing with the client about the altered perception encourages trust and promotes further client communication about hallucinations. The nurse must follow this by presenting the reality of the situation. Clients must be assisted in accepting that the perception is unreal to maintain reality orientation.
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms? 1. "I just feel so hopeless." 2. "The government has been watching my house." 3. "I'm unable to remember to brush my teeth." 4. "I no longer enjoy the activities I use to love."
3 Rationale: The nurse should recognize that memory impairment is a cognitive symptom of schizophrenia. Other cognitive symptoms include impaired concentration, judgement, and problem-solving.
A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? 1. "Her mannerologies are poor." 2. "My dog blank a boat to supreme heights." 3. "I can play the flute while wearing a suit. You are cute." 4. "My joints ache. My friend is the joint."
3 Rationale: The nurse should recognize that this statement is an example of clang association. Clang association refers to words that are based on sound rather than meaning. A client who has schizophrenia will often use words that rhyme or have a similar beginning sound.
A nurse in an acute mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse include in the plan? 1. Encourage the client to focus on personal hygiene 2. Limit the hours the client sleeps each day 3. Instruct the client to practice thought-stopping 4. Make negative statements about the client's behavior
3 Rationale: The nurse should teach the client who has OCD to use thought-stopping. By saying "stop" out loud, the client can learn to interrupt obsessive thoughts.
A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses the client's problem that this symptom may generate? 1. Disturbed thought processes 2. Disturbed sensory perception 3. Risk for suicide 4. Impaired verbal communication
3. Risk for suicide Rationale: Risk for suicide is defined as a risk for self-inflicted, life-threatening injury. The negative symptom of anhedonia is defined as the inability to experience pleasure. This is a particularly distressing symptom that generates hopelessness and compels some clients to attempt suicide.
A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for venlafaxine. Which of the following statements should the nurse make? 1. "This medication is only for short-term use." 2. "This medication can be taken on an as-needed basis." 3. "This medication will effectively reduce your physical manifestations of anxiety." 4. "This medication should not be stopped abruptly."
4 Rationale: The nurse should instruct the client that stopping venlafaxine abruptly will lead to manifestations of withdrawal.
A nurse is evaluating teaching for a client who has bipolar disorder disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching? 1. "I should take lithium on an empty stomach." 2. "I can take ibuprofen for headaches while taking lithium." 3. "I need to limit my salt intake while taking lithium." 4. "I am likely to gain weight while taking lithium."
4 Rationale: The nurse should instruct the client to eat a low-calorie diet while taking lithium because this medication can cause weight gain.
A nurse is assessing a client who has schizophrenia. The client states, "I need to get my gummamoshu from by my house." The nurse recognizes the statement as a example of which of the following? 1. Flight of ideas 2. Echolalia 3. Preservation 4. Neologism
4 Rationale: The nurse should recognize the client's response as a neologism, an invented word which has no meaning to others.
The nurse on an in-patient pediatric psychiatric unit is admitting a client diagnosed with autism spectrum disorder. Which would the nurse expect to assess? 1. A strong connection with siblings 2. An active imagination 3. Abnormalities in physical appearance 4. Absence of language
4. Absence of language Rationale: One of the first characteristics that the nurse would note is the client's abnormal language pattering or total absence of language. Children diagnosed with autism spectrum disorder display an uneven development of intellectual skills. Impairments are noted in verbal and nonverbal communication. These children cannot use or understand abstract language, and they may make unintelligible sounds or say the same word repeatedly.
A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? 1. Hallucinations 2. Impaired memory 3. Dysphoria 4. Social discomfort
4. Social discomfort Rationale: The absence of something that should be present is considered a negative symptom of schizophrenia. Social discomfort, the inability to enjoy activities, r a lack of goal-directed behavior are negative symptoms of schizophrenia.
