mental health exam 3

The nurse is administering risperidone to a client diagnosed with schizophrenia. The nurse anticipates the medication to have a therapeutic effect on which symptoms? Select all that apply. o A Somatic delusions o B Social isolation o C Gustatory hallucinations o D Flat affect o E Clang associations

-Somatic delusions -Gustatory hallucinations -Clang associations

The charge nurse on an inpatient psychiatric floor is teaching a floor nurse about signs and symptoms of alcohol withdrawal. The charge nurse knows the floor nurse demonstrates understanding when the floor nurse lists which of the following signs and symptoms? Select all that apply. o A Vomiting o B Tremors o C Bradycardia o D Hypotension o E hallucinations

-vomiting -tremors -hallucinations

A client comes in w/ signs of alcoholism and substance abuse. You as nurse know that genetic accounts for __% of clients vulnerability to alcoholism.

40%-60%

· A recovering alcoholic relapses and drinks a glass of wine. The client presents in the ED experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse recognizes that the client's symptoms indicate which of the following? A) Alcohol poisoning B) Cardiovascular accident (CVA) C) A reaction to disulfiram (Antabuse) D) A reaction to tannins in the red wine E) A reaction to disulfiram (Antabuse)

A reaction to disulffiram

The client is experiencing an episode of acute anxiety. The nurse will expect to observe which common coping behaviors? o A Social withdrawal o B Attention seeking o C Increased ability to problem solve o D Hypersomnia

A social withdrawal

An 18-year-old client who joined the military shortly after graduating from high school is admitted to the mental health unit for depression and suicidal ideation. He tells the nurse the military is not what he expected and he wants to go home. The nurse observes a variance in affect between his interaction with peers and staff. The nurse suspects: o A Conversion disorder o B Factitious disorder o C Malingering o D Conduct disorder

C Malingering

Chuck came into his parents' home and witnessed his parent's murder scene. The police and forensics arrived at this site and cordoned off the crime scene. Chuck was taken home by friends where he later reported blindness. A full examination was conducted at the hospital, where no physical reason for the blindness was found. The unlicensed assistive personnel asked the RN, what is the diagnosis? o A Hypochondria o B Illness Anxiety Disorder o C Conversion disorder o D Body dysmorphic

conversion disorder

A client is consciously stating she has neck pain and depression. What is the proper term? a) Malingering b) Factitious disorder c) Dissociative identify disorder d) La Belle Indifference

Factitious Disorder pretends to be ill to receive emotional care & support commonly associated w/ sympathy/ attention formerly known as Munchausen

A nurse working in an emergency department is caring for a patient who has alprazolam toxicity. Which of the following actions is the nurse's priority? o A Administer flumazenil o B Identify the patient's level of orientation o C Infuse I.V. Fluids o D Prepare the Patient for gastric lavage

o B Identify the patient's level of orientation. When taking the nursing process approach to client care, the initial step is assessment. Identifying the client's level of orientation is the priority action

A 21 year old client diagnosed with dissociative identity disorder, presents in the emergency department (ED) after attempting suicide. Which data obtained during the client's health history would support the current diagnosis? o A Recent drug abuse and living homelessness o B Sexual abuse by biological parent during childhood o C Unidentified continuous abdominal and neck pain o D Multiple somatic and psychological issues over the past 6 months

o B Sexual abuse by biological parent during childhood

· In assessing a potential client with Schizophrenia, which phase is research currently focused on in order to identify at-risk individuals as early as possible? o A The prodromal phase o B The residual phase o C The premorbid phase o D The active psychotic phase

o C The premorbid phase

How would the nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? o A GAD is acute in nature, and panic disorder is chronic. o B Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. o C Hyperventilation is a common symptom in GAD and rare in panic disorder. o D Depersonalization is commonly seen in panic disorder and absent in GAD.

o D Depersonalization is commonly seen in panic disorder and absent in GAD.

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) Visual hallucinations c) Restlessness and muscle rigidity d) Reports of hearing disturbing voicesa)

restlessness and muscle rigidity

The client is experiencing an episode of acute anxiety. The nurse will expect to observe which common coping behaviors? o A Social withdrawal o B Attention seeking o C Increased ability to problem solve o D Hypersomnia

social withdrawal

Who determines the length of time of a psychiatric facility can hold a patient?

state law (professionals can override treatment refusal if the client is actively suicidal or homicidal)

Which medication is given to patients for alcohol abuse? What is the patient education? a) Diphenhydramine b) Disulfram c) Chlorprmazine d) Methadone

Disulfram

amanda has been admitted to the hospital after being seen in an acute care walk-in clinic with blood in her urine. The admitting physician has ordered several invasive procedures: catheterization, blood work, and cystoscopy, among others. The physician does not know that Amanda has been taking anticoagulants to produce blood in her urine. The nurse is interviewing Amanda on her history. Which statement is most appropriate? o A "It must be terrible feeling ill all the time." o B "Your history doesn't make sense with your symptoms." o C "How would you describe your coping skills?" o D "Are you able to tell me about the onset and duration of your symptoms?

"Are you able to tell me about the onset and duration of your symptoms?

Which client statement alerts the nurse that the client may be maladaptively responding to stress? o A "I signed up for a yoga class this week." o B "I really enjoy journaling; it's my private time." o C "Avoiding contact with others helps me cope." o D "I made an appointment to meet with a therapist."

"Avoiding contact with others helps me cope."

What are the interventions for Somatic Symptom Disorder?

-Relief of discomfort from the physical sx -Assistance to determine strategies for coping with stress other than preoccupation w/ px sx - Help the client cope w/ stress, interpreting bodily sensations correctly -Stress management, providing support & encouragement & exploring the clients feelings and fears

Match the terms w/ POSITIVE or NEGATIVE symptom of schizophrenia? a) Hallucination b) Delusion c) Alogia or poverty of speech d) Catatonia e) Flat affect f) Paranoia g) Avolition or loss of motivation

*POSITIVE:* Hallucinations Delusions Cataonia Paranoria *Negative:* Flat affect Avolition or loss of motivation

List three examples of negative symptoms of schizophrenia

-Anergia (loss of energy) -Anhedonia (inability to experience pleasure) -Aphasia (loss of speech) -Ataxia (loss of full bodily movements)

· A nurse is working with a client that states being in public places causes them debilitating anxiety and even panic. Which therapies will the nurse provide education on? SATA. o A Electroconvulsive therapy (ECT) o B Flooding o C Systematic desensitization o D Cognitive Behavioral Therapy (CBT) o E Thought Stopping

-Flooding -Systematic desensitization -Cognitive Behavioral Therapy (CBT) -thought Stopping

A nurse is working with a client that states being in public places causes them debilitating anxiety and even panic. Which therapies will the nurse provide education on? SATA. o A Electroconvulsive therapy (ECT) o B Flooding o C Systematic desensitization o D Cognitive Behavioral Therapy (CBT) o E Thought Stopping

-Flooding, -Systematic desensitization -Cognitive Behavioral Therapy (CBT), -Thought Stopping

What are the three primary characteristics of Somatic Didsorder? a) Heightened emotionality b) depression c) anxiety d) strong dependency needs

-Heightened emotionality -anxiety -strong dependency needs *remember patients perception as an inability to cope* as apart of the disorder.

Amanda has been admitted to the hospital after being seen in an acute care walk-in clinic with blood in her urine. The admitting physician has ordered several invasive procedures: catheterization, blood work, and cystoscopy, among others. The physician does not know that Amanda has been taking anticoagulants to produce blood in her urine. What data will the nurse elicit from Amanda that will confirm this diagnosis? o A A history of multiple hospitalizations o B A history with few details o C An extensive history with a single provider o D A lack of understanding of medical terminology

A- A history of multiple hospitalizations

The nurse assesses a client who exhibits a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement indicates the nurse understands the characteristics of positive and negative symptoms of schizophrenia? o A Paranoia, anhedonia, and anergia are positive symptoms. o B Paranoia, neologisms, and echolalia are positive symptoms. o C Paranoia, anergia, and echolalia are negative symptoms. o D Paranoia, flat affect, and anhedonia are negative symptoms

B Paranoia, neologisms, and echolalia are positive symptoms

The nurse is caring for a client with phase III of schizophrenia. The nurse anticipates the patient will be exhibiting which signs or symptom the disorder? a) Active positive symptoms b) Normal behavior patters c) Active negative symptoms d) Shy and withdrawn, no wish to attend groups

Active positive sx

When working with a client that is non-compliant in treatment, what is the nurse's first intervention? a) Respect the client's decision and preserve their autonomy b) Address the reasons for non-compliance c) Notify the provider and place client in seclusion d) Reinforce the treatment plan

Address the reasons for non-compliance

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should nurse identify as a negative sx? a) affective flattening b) bizarre behavior c) illogicality d) somatic delusions

Affective flattening

A client states "I haven't left my house for six years" They're demonstrating a hallmark trait of what? a) aphasia b) anergia c) Agorphobia d) Annedonia

Agorphobia

During a nurse-client interaction, an adolescent client with a major depressive disorder stated, "I was on the swim team at school, but I don't enjoy swimming anymore so I quit." The client is describing: o A Aphasia o B Anergia o C Anhedonia o D Ataxia

Anheodonia

The nurse is educating the parents of a child dx w/ schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurses best replY?

Ask what are the voices are saying.

A nursing instructor is teaching about specific phobias. Which student statement indicates that learning has occurred? o A "These clients do not recognize that their fear is excessive, and they rarely seek treatment." o B "These clients have overwhelming symptoms of panic when exposed to the phobic stimulus." o C "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." o D "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."

B "These clients have overwhelming symptoms of panic when exposed to the phobic stimulus." Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response.

A male client with a recent diagnosis of depression is worried that medication will cause a lack of sexual interest. The nurse will anticipate the client being prescribed which psychotropic medication? o A Olanzapine o B Buproprion o C Phenelzine o D sertaline

Buproprion

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the past 24 hours. Which client symptom should the nurse immediately report to the ED physician? o A Bruising o B Blood pressure of 180/100 mmHg o C Mood rating of 2/10 o D Dehydration

BP of 180/100

A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with EPS of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order? a) Paroxetine (Paxil) b) Carbamazepine (Tegretol) c) Benztropine (Cogentin) d) Lorazepam (Ativan)

Benztropine

A patient is experiencing Hallucinations and paranoia. Is this positive or negative?

Both positive

Chuck came into his parents' home and witnessed his parent's murder scene. The police and forensics arrived at this site and cordoned off the crime scene. Chuck was taken home by friends where he later reported blindness. A full examination was conducted at the hospital, where no physical reason for the blindness was found. The unlicensed assistive personnel asked the RN, what is the diagnosis? o A Fugue o B Illness Anxiety Disorder o C Conversion disorder o D Body dysmorphic

Conversion disorder

A 22-year-old client with body dysmorphic disorder (BDD) tells the nurse that she plans to have a surgical procedure that will affect her appearance. The nurse understands that this plan is an effort to: o A Suppress intrusive thoughts o B Deal with multiple physical complaints o C Treat associated depression o D Cure the imagined defect

Cure the imagined defect

The nurse would express concern to the prescriber if the client has which of the following symptoms? o Command hallucinations o Delusions of grandeur o Tangential thinking o Thought blocking

Command hallucinations

A nurse is assessing a client who has hypochondriasis (illness anxiety disorder). Which of the following findings should the nurse expect? o A Constant worry about undiagnosed illness o B Obsession over physical appearance o C Sudden unexplained loss of function o D La Belle Indifference

Constant worry about undiagnosed illness

Chuck came into his parents' home and witnessed his parent's murder scene. The police and forensics arrived at this site and cordoned off the crime scene. Chuck was taken home by friends where he later reported blindness. A full examination was conducted at the hospital, where no physical reason for the blindness was found. The unlicensed assistive personnel asked the RN, what is the diagnosis? o A Hypochondria o B Illness Anxiety Disorder o C Conversion disorder o D Body dysmorphic

Conversion disorder

A Patient believes the FBI is out to get them what are they experiencing? · Another patient says they can see the FBI in the corner of the room, what are they experiencing?

Delusions Hallucinations

The nurse is working with a client diagnosed with Somatic Symptom Disorder. What predominant symptoms should the nurse expect to assess? A) Disproportionate and persistent thoughts about the seriousness of one's symptoms B) Amnestic episodes in which the client is pain free C) Excessive time spent discussing psychosocial stressor D) Lack of physical symptoms

Disproportionate and persistent thoughts about the seriousness of ones sx

· An inpatient client is newly diagnosed with anxiety disorder stemming from severe childhood sexual abuse. Which is the priority nursing intervention? o A Encourage exploration of sexual abuse. o B Encourage guided imagery. o C Establish trust and rapport. o D Administer antianxiety medications.

Est. trust and rapport

he nurse is working with a client who is being admitted to the psychiatric-mental health unit. The client was missing for two weeks was unaware that any time had passed after being found wandering the streets nowhere near his house. Which of the following dissociative disorders has this client experienced? a) Amnesia b) Depersonalization disorder c) Fugue d) Dissociative identity disorder (DID)

Fugue a person w/ dissociative fugue wanders, usually far from home and for days. During this time pt will forget their past life and associates

A client taking Phenelzine has a blood pressure of 210/119, a HR of 104 bpm, and diaphoresis. The nurse discovers the client has recently taken over the counter medication for allergies and a cold. The nurse recognizes this client is experiencing: A Hypertensiono B Neuroleptic Malignant Syndromeo C Hypertensive crisis D Serotonin Syndrome

Hypertensive crisis

The nurse is caring for a patient diagnosed with Conversion Disorder. Which statement made by the nurse is most therapeutic for this patient? A) "I think you could get over this condition if you tried hard enough. a positive outlook can change everything." B) "I'm so sorry that your back hurts so much. Yes, I'm happy to get you a wheelchair so you don't have to walk to meals." C) "I think that your symptoms are just in your head. Therapy can help you get rid of them." D) "I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties.

I am pleased to hear you ay that you recognize that your anxiety may be the cause of your swallowing difficulties

A client recently had an amputation of her legs however, she is not concerned. What is the proper term for this? a) Malingering b) Dysmorphic disorder c) Dissociative identify disorder d) La Belle Indifference

La Bell indifference

A client with bipolar disorder commands another client, "Change the television channel. Get me something to drink...," and so forth. The nurse wants to interrupt this behavior without entering into a power struggle. Select the nurse's best approach: o A Humor: "How much are you paying servants these days?" o B Bargaining: "If you stop ordering other patients around I will get you something to drink." C Honest feedback: "Your behavior is annoying other patients o D Distraction: "Let's go to the dining room for a snack." o D Distraction: "Let's go to the dining room for a snack."

Lets go to the dining room for a snack

This occurs when an individuals px or behavioral response to any change in his or her internal or external environment results in disruption of individual integrity or in persistent disequilibrium.

Maladaption/maladaptive coping skills

A client is pretending to have depression to be exucsed from jury duty. What is the proper term for this? a) Malingering b) Factitious disorder c) Dissociative identify disorder d) La Belle Indifference

Malingering This is an act, not psychological condition Pt will pretend to have a px or psychological condition in order to *gain* a reward or *avoid* something.

What are those that reflect a decrease in normal functions (functions that have been taking away) but the illness. Is this positive or negative sx of schizophrenia

Negative

The nurse is providing education to a client diagnosed with anxiety. Which statement by the client indicates that teaching has been effective? o A "Anxiety is part of who I am, I am powerless to change it." o B "Practicing yoga or meditation may help reduce my anxiety." o C "If I ignore the symptoms of anxiety, it will go away." o D "Medication is the only way to treat anxiety.

Practicing yoga or meditation may help reduce anxiety

This phase in Schizophrenia where patient manifests active positive sx

Pase 3- active phase

A nurse in an ER is caring for a client who is dx w/ acute alcohol withdrawal. Which of the following actions should the nurse take first? a) implement seizure precautions b) insert an IV access site c) perform a neurological exam d)obtain a blood specimen

Perform a neurological exam

What type of delusion is the "the government is watching everything I do."

Persecutory delusion

What is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate or intense anxiety response?

Phobia

During an intake assessment, the nurse asks a client physiological and psychosocial questions. The client angrily responds, "I'm here for my heart problems, not for my head." Which is the nurse's best response? o A "We ask all clients these questions." o B "Why are you concerned about these questions?" o C "Psychological stress can affect medical conditions." o D "We can skip these questions if you prefer."

Psychological stress can affect medical conditions

A 21 year old client diagnosed with dissociative identity disorder, presents in the emergency department (ED) after attempting suicide. Which data obtained during the client's health history would support the current diagnosis? o A Recent drug abuse and living homelessness o B Sexual abuse by biological parent during childhood o C Unidentified continuous abdominal and neck pain o D Multiple somatic and psychological issues over the past 6 month

Sexual abuse by biological parent during childhood

Warren's college roommate actively resists going out with friends whenever they invite him. He says he can't stand to be around other people and confides to Warren "They wouldn't like me anyway." Which disorder is Warren's roommate likely suffering from?

Social anxiety

Which disorder has physical sx that suggest medical disease but which have no organic pathology?

Somatic disorder

The nurse is assessing the client diagnosed with bipolar disorder. What assessment finding would cause the nurse to question possible substance abuse? o A The client is well-groomed and appears over nourished o B The client is disheveled and appears malnourished o C The client voices concern with mood changes o D The client states their family does not understand them

The client is disheveled and appears malnourished

Which statement indicates to the nurse that a client is experiencing a delusion? a) "The government is watching everything I do." b) "There is a snake on the back of the television." c) "spiders are crawling on the walls" d) "I don't care to do counseling today"

The government is watching everything I do.

A nurse is collecting past history data on a patient with acute stress disorder (ASD). Which of the following behaviors would the nurse anticipate finding? o A The patient remembers many details about the event o B The patient expresses a sense of elation about what is happening o C The patient notices manifestations of the disorder 30 days since the event occurred o D The patient expresses a sense of unreality concerning the traumatic event

The pt expressess a sense of unreality concerning the traumatic event

Wernicke's encephalopathy results from heavy chronic alcohol use and ______ deficiency

Thiamine or Vitamin B1

A client is brought to the emergency department. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dL. Among the physician's orders is thiamine. Which is the rationale for this intervention? a) To prevent nutritional deficits b) To prevent pancreatitis c) To prevent alcoholic hepatitis d) To prevent Wernicke's encephalopathy

To prevent Wernicke's encephalopathy (most serious form of thiamine deficiency seen w/ pt dx alcholism.

A client with suspected factitious disorder presents to the clinic with severe back pain rated 9/10. The nurse understands that: A) Treat the client's pain as real until determined otherwise B) Refuse to medicate because the client's condition is a ruse C) Send the client to another clinic D) Place the client on a psychiatric hold

Treat the clients pain as real until determined otherwise

A nurse is conducting a mental status exam. The nurse will assess for which of the following? (Select all that apply) o A thought content o B Grooming o C blood pressure o D Behavior E eye contact

a) thought content b) grooming d) behavior e) eye contact

A client who is experiencing alcohol withdrawal. which are the expected findings? a) muscle aches and chills b) fatigue and depression c) anxiety and diaphoresis d) arrhythmia and respiratory depression

anxiety and diaphoresis EARLY SIGNS: Anxiety, diaphoresis, irritability mood swings, tremors, dilated pupils, tachycardia, HTN, anorexia, & insomnia. sx intensify over 1-3 days after last drink Chronic use depresses CNS, and CNS stimulates and autonomic nervous system response.

client with a somatic symptom disorder presents to the community clinic describing abdominal pain, refuses to complete informational forms, and dismisses the nurse's assessment attempts while demanding to be seen immediately by a doctor. Which approach would be best for the nurse to use when assessing this client? o A Realize client judgment is intact. o B Have sympathy for the psychopathology of the disorder. o C Avoid personalizing the behavior of the client. o D Expect the client to respond appropriately to the nurse's need to complete the assessment.

avoid personalizing the behavior of the client.

Which below are examples of positive sx? a) affective flattening b) bizarre behavior c) illogicality d) somatic delusions

b) bizarre behavior c) illogicality d) somatic delusions

A nurse is caring for a client prescribed haloperidol for his chronic paranoid schizophrenia. Which complications should the nurse monitor? a) Chewing motion with the mouth b) Pin-point pupils c) Bradypnea d) Orthostatic hypotension e) Psychopharmacology

chewing motion w/ the mouth

Which medication below helps with a client who is experiencing acute manifestations of withdrawal from alcohol? a) diazepam b) acamprosate c)naltrexone d) disulfriam

diazepam (this is a benzodiazepine, used to treat ACUTE alcohol withdrawal.) helps w/ decreasing the intensity of withdrawal, prevents seizures, helps to stabilize vital signs.

A nurse is reinforcing teaching about alcohol tolerance. Which of the following statements by t he client indicates understanding? a) alcohol tolerance causes me to have an increased effect when taking opiates b) i will develop a decreased physical response to alcohol c) alcohol tolerance is medical emergency and can develop as a result of withdrawal.

i will develop a decreased physical response to alcohol

The nurse assigns Ineffective Coping as a nursing diagnoses for a client diagnosed with substance abuse. Which intervention does the nurse use to assist the patient to gain adaptive responses to stress? o A Spend time with the client and establish a trusting relationship o B Assign a new nurse daily to enable learning new coping skills o C Be inconsistent with pointing out negative or manipulative behaviors o D Discourage verbalization of feelings

o A Spend time with the client and establish a trusting relationship

when working with a client that is non-compliant in treatment, what is the nurse's first intervention? o A Respect the client's decision and preserve their autonomy o B Address the reasons for non-compliance o C Notify the provider and place client in seclusion o D Reinforce the treatment plan

o B Address the reasons for non-compliance

During a nurse-client interaction, an adolescent client with a major depressive disorder stated, "I was on the basketball team at school, but I don't have the energy to play so I quit." The client is describing: o A Aphasia o B Anergia o C Anhedonia o D Ataxia

o B Anergia