Mental health exam N4

A client diagnosed with borderline personality disorder is admitted to a psychiatric unit with recent self-inflicted cuts to both arms. Which of the following would explain this behavior? Select all that apply. 1. Self-mutilation is a manipulative gesture designed to elicit a rescue response. 2. Self-mutilation is often attempted when a "safety" plan has been established. 3. Self-mutilation proposes that feeling pain is better than feeling nothing. 4. Self-mutilation results from feelings of abandonment following separation from significant others. 5. Self-mutilation is attempted when voices tell the client to do self-harm.

.1,2,3,4 1.Clients diagnosed with borderline person- ality disorder often manipulate to attain desired goals. Self-mutilation can be a form of manipulation as well as an expres- sion of underlying emotional pain. 2. Clients diagnosed with borderline person- ality disorder often build in a "safety" plan when attempting self-mutilation, such as superficial cutting and then asking the nurse for first aid. This is evidence that self-mutilation is not always an actual suicide attempt. 3. Clients diagnosed with borderline person- ality disorder often use self-mutilation in an attempt to feel physical rather than emotional pain. These clients describe the pain felt on self-mutilation as a relief and a release of emotional pain. 4. Clients diagnosed with borderline person- ality disorder fear abandonment, which is frequently part of their past history. The pain of being abandoned is intolerable, and the client seeks relief by experiencing the physical pain of self-mutilation.

A nurse is assessing a client in the mental health clinic. The client has a long history of being a loner and has few social relationships. This client's father has been diagnosed with schizophrenia. The nurse would suspect that this client is in what phase in the development of schizophrenia? 1. Phase I—schizoid personality. 2. Phase II—prodromal phase. 3. Phase III—schizophrenia. 4. Phase IV—residual phase.

1 Individuals diagnosed with schizoid per- sonality disorder are typically loners who appear cold and aloof and are indifferent to social relationships. Not all individuals who demonstrate the characteristics of schizoid personality disorder progress to schizophrenia, but because of a family history of schizophrenia, this client's risk for acquiring the disease increases from 1% in the general population to 10%.

A client diagnosed with antisocial personality disorder is observed smoking in a non- smoking area. Which initial nursing intervention is appropriate? 1. Confront the client about the behavior. 2. Tell the client's primary nurse about the situation. 3. Remind all clients of the no smoking policy in the community meeting. 4. Teach alternative coping mechanisms to assist with anxiety.

1 It is important to address an individual's behavior in a timely manner to set appro- priate limits. Limit setting is to be done in a calm, but firm, manner. A client diag- nosed with antisocial personality disorder may have no regard for rules or regula- tions, which necessitates limit setting by the nurse.

A client is newly prescribed lithium carbonate (lithium). Which teaching point by the nurse takes priority? 1. "Make sure your salt intake is consistent." 2. "Limit your fluid intake to 2000 mL/day." 3. "Monitor your caloric intake because of potential weight gain." 4. "Get yourself in a daily routine to assist in avoiding relapse."

1 Lithium is similar in chemical structure to sodium, behaving in the body in much the same manner and competing with sodium at various sites in the body. If sodium intake is reduced, or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, and this increases the potential for toxicity.

A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. This level is indicative of which finding? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal

1 Rationale: Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L. Symptoms of toxicity begin to appear at levels of 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage and possible peritoneal dialysis or hemodialysis.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions

1 Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.

A client on an in-patient psychiatric unit is prescribed lamotrigine (Lamictal) 50 mg QD. After client teaching, which client statement reflects understanding of important information related to lamotrigine? 1. "I know the importance of reporting any alteration in my medication schedule." 2. "I will schedule an appointment for my blood to be drawn at the lab next week." 3. "I will call the doctor immediately if my temperature rises above 100°F." 4. "I will stop my medication if I start having muscle rigidity of my face or neck."

1 When the medication is titrated incorrectly, the risk for Stevens-Johnson syndrome increases. Clients need to be taught the importance of taking the medication as prescribed and accurately reporting compliance.

A client diagnosed with a thought disorder is experiencing clang associations. Which nursing diagnosis reflects this client's problem? 1. Impaired verbal communication. 2. Risk for violence. 3. Ineffective health maintenance. 4. Disturbed sensory perception.

1 Impaired verbal communication is defined as the decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols. Clang associations are choices of words that are governed by sound. Words often take the form of rhyming. An example of a clang association is "It is cold. I am bold. The gold has been sold." This type of language is an impairment to verbal communication.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1, 3, 4, 6 Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying means of setting limits on personal behaviors. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights.

A client has been prescribed ziprasidone (Geodon) 40 mg bid. Which of the following interventions are important related to this medication? Select all that apply. 1. Obtain a baseline EKG initially and periodically throughout treatment. 2. Teach the client to take the medication with meals. 3. Monitor the client's pulse because of the possibility of palpitations. 4. Institute seizure precautions, and monitor closely. 5. Watch for signs and symptoms of a manic episode.

1,2,3 1. Ziprasidone (Geodon) has the potential, in rare cases, to elongate the QT interval; a baseline and periodic EKG would be necessary. 2. Ziprasidone (Geodon) needs to be taken with meals for it to be absorbed effectively. It is important for the nurse to teach the client the need to take ziprasidone with meals. 3. Palpitations can be a side effect of ziprasi- done (Geodon) and would need to be monitored.

According to the DSM-IV-TR, which of the following diagnostic criteria define avoidant personality disorder? Select all that apply. 1. Does not form intimate relationships because of fear of being shamed or ridiculed. 2. Has difficulty making everyday decisions without reassurance from others. 3. Is unwilling to be involved with people unless certain of being liked. 4. Shows perfectionism that interferes with task completion. 5. Views self as socially inept, unappealing, and inferior.

1,3,5 1.Clients diagnosed with avoidant personality disorder show a pervasive pattern of social inhibitions, feelings of inadequacies, and hypersensitivity to negative evaluation, and find it difficult to form intimate relationships. 3.Clients diagnosed with avoidant personality disorder are extremely sensitive to rejection and need strong guarantees of uncritical acceptance. 5.Although there may be a strong desire for companionship, a client with avoidant per- sonality disorder has such a pervasive pat- tern of inadequacy, social inhibition, and withdrawal from life that the desire for companionship is negated.

A client diagnosed with schizophrenia is brought to the ER by a family member. The client is experiencing social withdrawal, flat affect, and impair- ment in role functioning. To distinguish whether this client is in the prodromal or residual phase of schizophrenia, what question would the nurse ask? 1. "Has this client recently experienced an exacerbation of the signs and symptoms of schizophrenia?" 2. "How long have these symptoms been occurring?" 3. "Has the client had a change in mood?" 4. "Has the client been diagnosed with any developmental disorders?"

1. It is important for the nurse to know if this client has recently experienced an active phase of schizophrenia to distin- guish the symptoms presented as indica- tions of the prodromal or residual phase of schizophrenia. Schizophrenia is characterized by periods of remission and exacerbation. A residual phase usually follows an active phase of the illness. Symptoms during the residual phase are similar to those of the prodromal phase, with flat affect and impairment in role function being prominent.

A client diagnosed with borderline personality disorder superficially cut both wrists, is disruptive in group, and is "splitting" staff. Which nursing diagnosis would take priority? 1. Risk for self-mutilation R/T need for attention. 2. Ineffective coping R/T inability to deal directly with feelings. 3. Anxiety R/T fear of abandonment AEB "splitting" staff. 4. Risk for suicide R/T past suicide attempt.

1. Repetitive, self-mutilating behaviors are classic manifestations of borderline per- sonality disorder. These individuals seek attention by self-multilating until pain is felt in an effort to counteract feelings of emptiness. Some clients reported that "to feel pain is better than to feel nothing." Because these clients often inflict injury on themselves, this diagnosis must be prioritized to ensure client safety.

The nurse is assessing a client diagnosed with schizophrenia. The client states, "We wanted to take the bus, but the airport took all the traffic." Which charting entry accu- rately documents this symptom? 1. "The client is experiencing associative looseness." 2. "The client is attempting to communicate by the use of word salad." 3. "The client is experiencing delusional thinking." 4. "The client is experiencing an illusion involving planes."

1. Associative looseness is thinking charac- terized by speech in which ideas shift from one unrelated subject to another. The client is unaware that the topics are unconnected. The client statement is an example of associative looseness.

A client diagnosed with a personality disorder states, "You are the very best nurse on the unit and not at all like that mean nurse who never lets us stay up later than 9 p.m." This statement would be associated with which personality disorder? 1. Borderline personality disorder. 2. Schizoid personality disorder. 3. Passive-aggressive personality disorder. 4. Paranoid personality disorder.

1. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality dis- orders. Clients diagnosed with borderline personality disorder are characterized by a marked instability in interpersonal rela- tionships, mood, and self-image. Clients with this disorder attempt to pit one indi- vidual against another. This is known as "splitting" and is related to an inability to integrate and accept positive and negative feelings. Splitting is a primitive ego defense mechanism that is common in individuals with borderline personality disorder. In the question, the client's statement typifies splitting behavior.

A family member wants to know the difference between Alzheimer's disease and delirium. Which explanation should the nurse provide to the family member? 1) Delirium is a reversible condition, whereas Alzheimer's disease is not. 2) The treatment for Alzheimer's disease is more aggressive than is the treatment for delirium. 3) There are more stigmas associated with a diagnosis of Alzheimer's disease than with delirium. 4) Changes in cognition develop rapidly with Alzheimer's disease, and slowly with delirium.

1: Alzheimer's disease is irreversible as compared to delirium, which in most cases is reversible.

The community health nurse should include which primary level of prevention intervention for a homeless, unemployed individual? 1) Providing education and support 2) Referring to homeless shelter 3) Teaching daily living skills to encourage independence 4) Referring to an inpatient psychiatric hospital

1: Providing education and support to unemployed or homeless individuals is a primary level of prevention concept that targets both the individual and the environment. Primary prevention services are aimed at reducing the incidence of mental health disorders in the population.

A despondent, recently widowed woman tells the home health nurse, "My dead husband is lucky! I'm so lonely, there's no one to talk to, and life is not worth living with this arthritis pain." Which nursing diagnosis takes priority? 1) Risk for suicide 2) Social isolation 3) Pain 4) Dysfunctional grieving

1: Risk for suicide applies when an individual is at risk for self-inflicted, life-threatening injury. The client's statements indicate feelings of abandonment, hopelessness, and a possible threat to end her life. The nursing diagnosis of risk for suicide would take priority because the client's safety may be in jeopardy, and client safety is always prioritized.

A client diagnosed with schizophrenia states, "My roommate is plotting to have others kill me." Which is the appropriate nursing response? 1) "I find that hard to believe." 2) "What would make you think such a thing?" 3) "I know your roommate. He would do no such thing." 4) "I can see why you feel that way."

1: This client is experiencing a persecutory delusion. This nursing response is an example of "voicing doubt," which expresses uncertainty as to the reality of the client's perceptions. This is an appropriate therapeutic communication technique in dealing with clients experiencing delusional thinking.

A client tells the nurse, "You're so much nicer than that mean nurse on nightshift." This statement would be associated with which personality disorder? 1) Borderline personality disorder 2) Narcissistic personality disorder 3) Schizotypal personality disorder 4) Avoidant personality disorder

1: This statement would be typical of a client diagnosed with borderline personality disorder. These clients typically generate conflict in a maladaptive attempt to gain attention and acceptance. They use "splitting," which is an ego defense manifested by an inability to integrate and accept both positive and negative feelings. Individuals, including themselves, are viewed as either all good or all bad.

Family members are considering home care for a client diagnosed with neurocognitive disorder. Which initial nursing intervention would be most appropriate before the family makes that decision? 1) Teach the family about the disease process and the skills necessary to manage client care. 2) Encourage family to address any unresolved issues or resentments with the client. 3) Determine the extent of the family's financial resources. 4) Include the client in the decision-making process.

1: To make the best immediate decisions for this client, the family must be knowledgeable about the disease process of dementia and the skills needed to care for their family member. With this knowledge, they can make informed decisions about treatment.

A withdrawn client newly diagnosed with schizophrenia is experiencing delusional thinking. Which nursing intervention is most appropriate? 1) Present objective reality. 2) Use self-disclosure. 3) Use physical touch for reassurance. 4) Explain in depth, unit rules and regulations

1: When communicating with a client diagnosed with schizophrenia, the nurse should reinforce and focus on reality by talking about real events and real people. Discussions that focus on false ideas reinforce the client's delusions.

A client diagnosed with a substance use disorder is experiencing delirium related to alcohol withdrawal syndrome. Which nursing intervention should be prioritized? 1) Maintain seizure precautions. 2) Restrict fluid intake. 3) Increase sensory stimuli. 4) Apply ankle and wrist restraints.

1: Withdrawal delirium symptoms develop during the first week of reduction or termination of sustained, usually high-dose use of certain substances, such as alcohol, sedatives, hypnotics, or anxiolytics. Clients experiencing alcohol withdrawal are at high risk for seizures. This is a priority intervention because seizures can be life threatening.

A client experiencing command hallucinations is hospitalized after jumping from a bridge. The client's parents insist that their son fell rather than jumped. Which of the following best explains the parents' response? Select all that apply. 1) The parents are in denial about the reality of their son's mental illness. 2) The parents are grieving over the loss of their expectations for their child. 3) The parents do not understand the extent or seriousness of mental illness. 4) The parents reject the idea of their son having a mental illness. 5) The parents are showing support for their son

1: By stating the jump was a fall, the parents are expressing denial and minimizing the problem. 2: The child's attempted suicide could generate a loss of hope that their child will meet parental expectations. This can occur any time a child is physically or mentally different. 3: The parents may have a knowledge deficit and truly may not understand the implications of their child's mental illness. 4: By claiming that their son fell rather than jumped from the bridge, the parents are embracing an accidental cause and rejecting the possibility of mental illness.

In developing a community-based care plan, the community health nurse should address which of the following ongoing problems for homeless individuals? Select all that apply. 1) Alcoholism and thermoregulation 2) Sexually transmitted diseases 3) Conditions related to dietary deficiencies 4) Tuberculosis 5) The aging process

1: One of the major afflictions of homeless individuals is alcoholism. Thermoregulation is a health problem for homeless individuals because of their exposure to all kinds of weather. It is a compounded problem for the homeless alcoholic who spends much time in an altered level of consciousness. 2: Sexually transmitted diseases, such as gonorrhea and syphilis, are serious problems for the homeless. Human immunodeficiency virus (HIV) is increasing among the homeless population. Reports indicate that the prevalence of HIV is at least three times higher than in the general population. 3: Dietary deficiencies are a continuing problem for homeless individuals. Not only is the homeless person commonly in a poor nutritional state, but these deficiencies also exacerbate a number of other health problems. 4: Tuberculosis is a growing problem among individuals who are homeless. Crowded shelters provide ideal conditions for the spread of respiratory infections among their inhabitants. The risk of acquiring tuberculosis is also increased by the prevalence of alcoholism, drug addiction, HIV infection, and poor nutrition.

What is required for effective treatment of schizophrenia? 1. Concentration on pharmacotherapy alone to alter imbalances in neurotransmitters. 2. Multidisciplinary, comprehensive efforts, which include pharmacotherapy and psy- chosocial care. 3. Emphasis on social and living skills training to help the client fit into society. 4. Group and family therapy to increase socialization skills.

2 Effective treatment of schizophrenia requires a comprehensive, multidiscipli- nary effort, including pharmacotherapy and various forms of psychosocial care. Psychosocial care includes social and living skills training, rehabilitation, and family therapy.

Which intervention describes an important component in the treatment of clients diagnosed with personality disorders? 1. Psychotropic medications are prescribed to reduce hospitalizations. 2. Self-awareness by the nurse is necessary to ensure a therapeutic relationship. 3. Group therapy, not individual therapy, is the preferred approach. 4. Addressing comorbid issues is not indicated.

2 Individuals diagnosed with personality disorders attempt to get their needs met in any way possible, including manipula- tion. It is critical for nurses working with clients diagnosed with personality disor- ders to be aware of and discuss their frus- trations in order to be therapeutic with these clients.

A nurse is working with a client diagnosed with schizoid personality disorder. What symptom of this diagnosis should the nurse expect to assess, and at what risk is this client for acquiring schizophrenia? 1. Delusions and hallucinations—high risk. 2. Limited range of emotional experience and expression—high risk. 3. Indifferent to social relationships—low risk. 4. Loner who appears cold and aloof—low risk.

2 Individuals diagnosed with schizoid per- sonality disorder are indifferent to social relationships and have a very limited range of emotional experience and expres- sion. They do not enjoy close relation- ships and prefer to be loners. They appear cold and aloof. Not all individuals who demonstrate the characteristics of schizoid personality disorder progress to schizophrenia, but most individuals diag- nosed with schizophrenia show evidence of the characteristics of schizoid personal- ity disorder premorbidly, putting them at high risk for schizophrenia.

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2 Rationale: Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurse's station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2 Rationale: Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.

A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depression

2 Rationale: Sertraline (Zoloft) is classified as an antidepressant. Sertraline (Zoloft) generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline (Zoloft) is not prescribed for use as needed.

The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1. Parkinsonism 2. Tardive dyskinesia 3. Hypertensive crisis 4. Neuroleptic malignant syndrome

2 Rationale: Tardive dyskinesia is a reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Parkinsonism is characterized by tremors, masklike facies, rigidity, and a shuffling gait. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity.

The nurse is teaching a client who is being started on imipramine (Tofranil) about the medication. The nurse should inform the client to expect maximum desired effects at what time period following initiation of the medication? 1. In 2 months 2. In 2 to 3 weeks 3. During the first week 4. During the sixth week of administration

2 Rationale: The maximum therapeutic effects of imipramine (Tofranil) may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side/adverse effects of the medication? 1. Cardiovascular symptoms 2. Gastrointestinal dysfunctions 3. Problems with mouth dryness 4. Problems with excessive sweating

2 Rationale: The most common side/adverse effects related to this medication include central nervous system and gastrointestinal system dysfunction. Fluoxetine (Prozac) affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Cardiovascular symptoms, dry mouth, and excessive sweating are not side/adverse effects associated with this medication.

A suicidal client is diagnosed with borderline personality disorder. Which short-term outcome is most beneficial for the client? 1. The client will be free from self-injurious behavior. 2. The client will express feelings without inflicting self-injury by discharge. 3. The client will socialize with peers in the milieu by day 3. 4. The client will acknowledge the client's role in altered interpersonal relationships.

2 The client's being able to express feelings without inflicting self-injury by discharge is an outcome that reinforces the priority for client safety, is measurable, and has a timeframe.

After being treated in the ED for self-inflicted lacerations to wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority? 1. Administer tranquilizing drugs. 2. Observe client frequently. 3. Encourage client to verbalize hostile feelings. 4. Explore alternative ways of handling frustration.

2 The priority nursing intervention is to observe the client's behavior frequently. The nurse should do this through routine activities and interactions to avoid appearing watchful and suspicious. Close observation is required so that immediate interventions can be implemented as needed.

The nurse reports that a client diagnosed with a thought disorder is experiencing reli- giosity. Which client statement would confirm this finding? 1. "I see Jesus in my bathroom." 2. "I read the Bible every hour so that I will know what to do next." 3. "I have no heart. I'm dead and in heaven today." 4. "I can't read my Bible because the CIA has poisoned the pages."

2 The statement, "I read the Bible every hour so that I will know what to do next," is evidence of the symptom of religiosity. Religiosity is an excessive demonstration of or obsession with religious ideas and behavior. The client may use religious ideas in an attempt to provide rational meaning and structure to behavior.

The nurse states, "It's time for lunch." A client diagnosed with schizophrenia responds, "It's time for lunch, lunch, lunch." Which type of communication process is the client using, and what is the underlying reason for its use? 1. Echopraxia, which is an attempt to identify with the person speaking. 2. Echolalia, which is an attempt to acquire a sense of self and identity. 3. Unconscious identification to reinforce weak ego boundaries. 4. Depersonalization to stabilize self-identity.

2 When clients diagnosed with schizophre- nia repeat words that they hear, they are exhibiting echolalia. This is an indication of alterations in the client's sense of self. Weak ego boundaries cause these clients to lack feelings of uniqueness. Echolalia is an attempt to identify with the person speaking.

According to the DSM-IV-TR, which of the following diagnostic criteria define bor- derline personality disorder? Select all that apply. 1. Arrogant, haughty behaviors or attitudes 2. Frantic efforts to avoid real or imagined abandonment. 3. Recurrent suicidal and self-mutilating behaviors. 4. Unrealistic preoccupation with fears of being left to take care of self. 5. Chronic feelings of emptiness.

2,3,5 1.This criterion describes borderline per- sonality disorder, which is characterized by a pervasive pattern of instability of interpersonal relationships. Real or imag- ined feelings of abandonment are the first criterion of this disorder. 3.Recurrent suicidal and self-mutilating behavior is the fifth DSM-IV-TR diagnos- tic criterion that describes borderline per- sonality disorder. 5.Chronic feelings of emptiness are the sev- enth DSM-IV-TR diagnostic criterion that describes borderline personality disorder.

On an in-patient unit, the nurse is caring for a client who is assuming bizarre positions for long periods of time. To which diagnostic category of schizophrenia would this client most likely be assigned? 1. Disorganized schizophrenia. 2. Catatonic schizophrenia. 3. Paranoid schizophrenia. 4. Undifferentiated schizophrenia.

2. A client diagnosed with catatonic schizo- phrenia exhibits marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movements and activity. Waxy flexibility is exhibited. Waxy flexibility is a type of posturing or volun- tary assumption of bizarre positions in which the individual may remain for long periods. Efforts to move the individual may be met with rigid bodily resistance. The client described in the question is exhibiting signs and symptoms of catatonic schizophrenia.

A client diagnosed with borderline personality disorder ingratiatingly requests diazepam (Valium). When the emergency department physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the client using? 1. Undoing. 2. Splitting. 3. Altruism. 4. Reaction formation.

2. The client in the question is using the defense mechanism of splitting. An indi- vidual diagnosed with borderline personal- ity disorder sees things as either "all good" or "all bad." In the question, when the client's manipulative charm does not work in obtaining the drug from the "good" physician, the client determines that the physician is now "bad" and seeks another physician to meet his or her needs.

A client has been diagnosed with a cluster A personality disorder. Which client state- ment would reflect cluster A characteristics? 1. "I'm the best chef on the East Coast." 2. "My dinner has been poisoned." 3. "I have to wash my hands 10 times before eating." 4. "I just can't eat when I'm alone."

2. This statement might be voiced by a client diagnosed with paranoid personality disorder. Cluster A includes paranoid, schizoid, and schizotypal personality dis- orders. This cluster's characteristic behav- iors are odd or eccentric and include pat- terns of suspiciousness and mistrust.

A financially secure client diagnosed with schizophrenia angrily states, "I've been taking Risperdal for 5 years. I can't afford the medication so I am not taking it anymore." Which defense mechanism is this client using? 1) Regression 2) Rationalization 3) Sublimation 4) Projection

2: Rationalization is used when an individual attempts to justify behaviors that are not socially acceptable. The client in the question is justifying medication noncompliance by claiming imaginary financial need.

A nursing home resident taking antipsychotic medications complains to the nurse of a stiff neck and difficulty swallowing. These symptoms are indicative of which condition? 1) Dysphonia 2) Tardive dyskinesia 3) Akathisia 4) Echolalia

2: Tardive dyskinesia is a syndrome of symptoms characterized by bizarre facial and tongue movements, a stiff neck, and difficulty swallowing. This condition may occur as an adverse effect of long-term therapy with antipsychotic medications.

A client is admitted to the hospital with possible Alzheimer's disease. The family asks the nurse what tests will be performed to determine this diagnosis. What is the correct nursing response? 1) Dexamethasone suppression test 2) Magnetic resonance imagery (MRI) 3) Thematic apperception test 4) Family kinetic drawing

2: An MRI can reveal atrophy, widened cortical sulci, and enlarged cerebral ventricles. This degenerative pathology is indicative of Alzheimer's disease. However, a definitive diagnosis cannot be done until autopsy.

Hospitalized and diagnosed in the fourth stage of Alzheimer's disease, a client, when asked about the previous evening, describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting? 1) Aphasia 2) Confabulation 3) Delirium 4) Apraxia

2: Confabulation is a behavioral reaction to memory loss in which the client fills in memory gaps with information about events that have not occurred. During the fourth stage of Alzheimer's disease, a client will use confabulation in an effort to maintain self-esteem.

A nursing student is learning about schizotypal personality disorder. Which statement by the student indicates that learning has occurred? 1) "These individuals have peculiarities of ideation." 2) "These individuals display irresponsible and guiltless behavior." 3) "These individuals are overly disciplined and perfectionistic." 4) "These individuals have an unrealistic sense of entitlement."

2: Displaying irresponsible and guiltless behavior is characteristic of clients diagnosed with antisocial, not schizotypal, personality disorders.

A nursing home resident is often argumentative with other residents and staff and frequently exhibits loss of emotional control. Which nursing intervention should the nurse implement? 1) Confront the argumentative behavior. 2) Redirect attention and set limits on maladaptive, abusive behavior. 3) Administer prn medications to subdue the client. 4) Isolate the client until the behavior improves.

2: Maladaptive, abusive behavior must be curtailed by the use of limit setting and redirection. Setting limits provides a sense of security and stability for the client and maintains a safe environment.

Which homebound status criterion must be validated before an individual can receive home health care? 1) Client takes fluphenazine (Prolixin) PO for schizophrenia. 2) Client is unable to leave home without assistance. 3) Client does not have available family support. 4) Client has been diagnosed with major depressive episode.

2: The client must show that he or she is unable to leave the home without considerable difficulty or the assistance of another person in order to meet criteria for homebound status. This criterion must be validated.

A mute client diagnosed with schizophrenia displays catatonia and waxy flexibility. Which nursing intervention would assist the client in communicating with others? 1) Providing assistance with self-care needs 2) Using clear, concrete statements 3) Conveying acceptance of client's need for false beliefs 4) Attempting to decode incomprehensible communication patterns

2: The use of clear, concrete statements shows the client what is expected. Because clients diagnosed with schizophrenia experience concrete thinking, explanations must be provided at the client's concrete level of comprehension.

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 A persecutory delusion is a type of delusion in which the individual believes he or she is being malevolently treated in some way. Frequent themes include being conspired against, cheated, spied on, followed, poi- soned 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 diagnosed with antisocial personality disorder states, "My kids are so busy at home and school they don't miss me or even know I'm gone." Which nursing diagnosis applies to this client? 1. Risk for injury. 2. Risk for violence: self-directed. 3. Ineffective denial. 4. Powerlessness

3 Ineffective denial is defined as the con- scious or unconscious attempt to disavow knowledge or meaning of an event to reduce anxiety or fear. The client presented in the question is denying his or her children's need for parental support by turning the situation around and making himself or herself sound like the victim who is not needed.

The client hears the word "match." The client replies, "A match. I like matches. They are the light of the world. God will light the world. Let your light so shine." Which communication pattern does the nurse identify? 1) Word salad 2) Clang association 3) Loose association 4) Ideas of reference

3 Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question clearly represents this communication pattern.

The children's saying, "Step on a crack and you break your mother's back," is an exam- ple of which type of thinking? 1. Concrete thinking. 2. Thinking using neologisms. 3. Magical thinking. 4. Thinking using clang associations.

3 Magical thinking occurs when the individ- ual believes that his or her thoughts or behaviors have control over specific situa- tions or people. It is commonly seen dur- ing cognitive development in childhood. The statement presented is an example of magical thinking.

The nurse is assessing a client diagnosed with borderline personality disorder. According to Mahler's theory of object relations, which describes the client's unmet developmental need? 1. The need for survival and comfort. 2. The need for awareness of an external source for fulfillment. 3. The need for awareness of separateness of self. 4. The need for internalization of a sustained image of a love object/person.

3 Phase 3 (5 to 36 months) is the separation- individuation phase. The main task of this phase is the primary recognition of separateness from the mother figure. According to Mahler's theory, fixation in this phase may predispose the child to borderline personality.

The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch him.

3 Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"

3 Rationale: It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.

3 Rationale: The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

A client is prescribed aripiprazole (Abilify) 10 mg QAM. The client complains of seda- tion and dizziness. The client's vital signs are blood pressure 100/60 mm Hg, pulse 80, respiration rate 20, and temperature 97.4°F. Which nursing diagnosis takes priority? 1. Risk for noncompliance R/T irritating side effects. 2. Knowledge deficit R/T new medication prescribed. 3. Risk for injury R/T orthostatic hypotension. 4. Activity intolerance R/T dizziness and drowsiness.

3 Risk for injury R/T orthostatic hypoten- sion, which is a side effect of the medica- tion, is a priority diagnosis. It is important for nurses to recognize when a client is at increased risk for injury because of side effects such as orthostatic hypotension.

A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diag- nosis addresses concerns regarding this client's problem? 1. Disturbed thought processes. 2. Disturbed sensory perception. 3. Risk for suicide. 4. Impaired verbal communication.

3 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 client diagnosed with paranoid personality disorder is prescribed risperidone (Risperdal). The client is noted to have restlessness and weakness in lower extremities and is drooling. Which nursing intervention would be most important? 1. Hold the next dose of risperidone, and document the findings. 2. Monitor vital signs, and encourage the client to rest in room. 3. Give the ordered PRN dose of trihexyphenidyl (Artane). 4. Get a fasting blood sugar measurement because of potential hyperglycemia.

3 The symptoms noted are EPS caused by antipsychotic medications. These can be corrected by using anticholinergic med- ications, such as trihexyphenidyl (Artane), benztropine (Cogentin), or diphenhy- dramine (Benadryl).

The nurse documents that a client diagnosed with schizophrenia is expressing a flat affect. What is an example of this symptom? 1. The client laughs when told of the death of the client's mother. 2. The client sits alone and does not interact with others. 3. The client exhibits no emotional expression. 4. The client experiences no emotional feelings.

3 Flat affect is described as affect devoid of emotional tone. Having no emotional expression is an indication of flat affect.

A hospitalized client is started on phenelzine (Nardil) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad

3, 5 Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs.

A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with extrapyramidal symptoms (EPS) of restlessness, drooling, and tremors. What medication will the nurse expect the physician to order? 1) Paroxetine (Paxil) 2) Carbamazepine (Tegretol) 3) Benztropine (Cogentin) 4) Lorazepam (Ativan)

3: Cogentin is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for extrapyramidal symptoms. This is the drug of choice to treat extrapyramidal symptoms associated with side effects of antipsychotic medications.

When teaching a family about Alzheimer's disease, what information should the nurse include? 1) Alzheimer's disease is self-limiting and will resolve over time. 2) Alzheimer's disease has an abrupt onset and runs a variable course. 3) Alzheimer's disease has a slow and insidious onset. 4) Alzheimer's disease causes a rapid functional and cognitive decline.

3: Alzheimer's disease is characterized by a slow and insidious onset with progressive loss of cognitive abilities.

A client has recently been diagnosed with mild to moderate Alzheimer's disease. Which medication would the nurse expect the physician to order for this client's cognitive impairment? 1) Nortriptyline (Pamelor) 2) Zaleplon (Sonata) 3) Donepezil (Aricept) 4) Quetiapine (Seroquel)

3: Aricept is used to improve cognition in clients diagnosed with mild to moderate neurocognitive disorder associated with Alzheimer's disease. Its action improves cholinergic function by inhibiting acetylcholinesterase.

A client diagnosed with a personality disorder tells the nurse, "With my expertise, I could become this hospital's CEO tomorrow." This statement would be associated with which personality disorder? 1) Antisocial personality disorder 2) Obsessive-compulsive personality disorder 3) Narcissistic personality disorder 4) Avoidant personality disorder

3: Clients diagnosed with narcissistic personality disorder are often boastful and grandiose. These individuals have an exaggerated sense of self-worth. They believe that they have an inalienable right to receive special consideration and that their desire is sufficient justification for possessing whatever they seek.

A client diagnosed with borderline personality disorder presents to the mental health clinic and demands to see a counselor immediately. Which is the appropriate nursing action? 1) Instruct the client to leave the clinic. 2) Confront demanding behaviors. 3) Explain the rules and set limits. 4) Help the client problem solve.

3: Explaining rules and setting limits establishes clear boundaries. This provides the firm structure needed by a client diagnosed with borderline personality disorder. The nurse may state, "Clients are seen in the order of their scheduled appointments. It looks like it will be another 20 minutes before you are seen."

A client is in the third stage of Alzheimer's disease. Which characteristic is indicative of this stage? 1) The client has no apparent cognitive decline. 2) The client loses the ability to perform some activities of daily living. 3) The client is unable to plan or organize, and work performance declines. 4) The client is bedfast and aphasic

3: Interference with work performance becomes noticeable to coworkers, and the ability to plan and/or organize declines in the third stage of Alzheimer's.

A client is diagnosed with middle to late-stage neurocognitive disorder. Which client information should the nurse assess to effectively plan the client's care? 1) The client's past successful coping mechanisms 2) The client's willingness to participate in goal setting and treatment planning 3) The client's changes in level of functioning, including strengths and weaknesses 4) The client's attitude toward illness

3: Nursing assessments should include both strengths and weaknesses of the client. This assessment must be ongoing in order to adapt nursing care to the client's current level of functioning.

The nurse is providing care for an emaciated client experiencing an acute phase of catatonic stupor. Which nursing intervention would take priority when meeting this client's needs? 1) Provide speech therapy for mutism. 2) Provide physical therapy for psychomotor retardation. 3) Provide nutrient-dense foods and beverages. 4) Provide a safe environment.

3: Nutrition is an essential consideration for a client experiencing catatonic stupor. The emaciated client in the question is suffering from a serious diet deficiency with possible anemia. The nurse must prioritize this basic physical need.

A client is admitted with a diagnosis of schizoaffective disorder. Which symptoms are characteristic of this diagnosis? 1) Strong ego boundaries and abstract thinking 2) Ataxia and akinesia 3) Altered mood and thought disturbances 4) Substance use disorder and cachexia

3: The characteristic symptoms of schizoaffective disorder are a combination of alterations in mood (mania or depression) and thought.

A client diagnosed with avoidant personality disorder states, "I've never been close to my daughter. I'm sure she will never have time for me." Which nursing diagnosis applies to this client? 1) Relocation stress syndrome 2) Risk for violence: other directed 3) Social withdrawal 4) Fear

3: The statement presented in the question suggests feelings of rejection leading to social withdrawal. The individual diagnosed with avoidant personality disorder is extremely sensitive to rejection and because of this, experiences a very socially withdrawn life. There may be a strong desire for companionship but extreme shyness and fear of rejection create a need for unusually strong guarantees of uncritical acceptance.

Which statement is correct concerning personality disorders? 1) Personality disorders generally emerge during adolescence. 2) Individuals diagnosed with personality disorders have insight into their disorder. 3) Personality disorders occur when personality traits become inflexible, maladaptive, and cause dysfunctional patterns of behavior. 4) Individuals diagnosed with personality disorders demonstrate adaptive ability to perceive and relate to themselves and the environment.

3: When either significant functional impairment or subjective distress occurs as a result of inflexible and maladaptive personality traits, a diagnosis of personality disorder can be made.

A client diagnosed with schizophrenia is experiencing disorganized thinking. Which technique should the nurse use to promote communication? 1) Giving broad openings 2) Probing 3) Verbalizing the implied 4) Using open-ended questions

3: When working with clients who have greatly impaired communication, the nurse can use the technique of verbalizing the implied. By putting into words what the client may be experiencing, the nurse helps the client organize his or her thinking.

A client newly admitted to an in-patient psychiatric unit is diagnosed with schizotypal personality disorder. The client states, "I can't believe you are not afraid of the mon- sters coming after us all." Which is the most appropriate nursing response? 1. "I don't know what monsters you are talking about." 2. "The monsters? Can you please tell me more about that?" 3. "I was wondering if you want to come to group to talk about that." 4. "I can see your thoughts are bothersome. How can I help?"

4 Acknowledging the client's feelings about the delusion is an important response. The nurse supports the client's feelings, but not the delusion. At the same time, the nurse explores ways to help the client feel comfortable.

A client diagnosed with schizoid personality disorder chooses solitary activities, lacks close friends, and appears indifferent to criticism. Which nursing diagnosis would be appropriate for this client's problem? 1. Anxiety R/T poor self-esteem AEB lack of close friends. 2. Ineffective coping R/T inability to communicate AEB indifference to criticism. 3. Altered sensory perception R/T threat to self-concept AEB magical thinking. 4. Social isolation R/T discomfort with human interaction AEB avoiding others.

4 Clients diagnosed with schizoid personality disorder are unsociable and prefer to work in isolation. These individuals are charac- terized primarily by a profound defect in the ability to form personal relationships or to respond to others in any meaningful or emotional way. They display a lifelong pattern of social withdrawal, and their discomfort with human interaction is very apparent. This client is choosing solitary activities and lacks friends. The nursing diagnosis social isolation is appropriate in addressing this client's problem.

Which atypical antipsychotic medication has the most potential for a client to experi- ence sedation, weight gain, and hypersalivation? 1. Haloperidol (Haldol). 2. Chlorpromazine (Thorazine). 3. Risperidone (Risperdal). 4. Clozapine (Clozaril).

4 Clozapine (Clozaril), an "atypical" antipsychotic, has side effects including sedation, weight gain, and hypersalivation. Because of these side effects and the life- threatening side effect of agranulocytosis, clozapine usually is used as a last resort after all other medications have been tried. Diagnostic lab tests need to be performed bimonthly.

A nurse is discharging a client diagnosed with narcissistic personality disorder. Which employment opportunity is most likely to be recommended by the treatment team? 1. Home construction. 2. Air traffic controller. 3. Night watchman at the zoo. 4. Prison warden.

4 Individuals diagnosed with narcissistic personality disorder have an exaggerated sense of self-worth and believe they have an inalienable right to receive special con- sideration. They tend to exploit others to fulfill their own desires. Because they view themselves as "superior" beings, they believe they are entitled to special rights and privileges. Because of the need to control others inherent in the job of prison warden, this would be an appropri- ate job choice for client diagnosed with narcissistic personality disorder.

Which predisposing factor would be implicated in the etiology of paranoid personality disorder? 1. The individual may have been subjected to parental demands, criticism, and perfec- tionistic expectations. 2. The individual may have been subjected to parental indifference, impassivity, or for- mality. 3. The individual may have been subjected to parental bleak and unfeeling coldness. 4. The individual may have been subjected to parental antagonism and harassment.

4 Individuals diagnosed with paranoid per- sonality disorder most likely would be subjected to parental antagonism and harassment. These individuals likely served as scapegoats for displaced parental aggression and gradually relinquished all hope of affection and approval. They learned to perceive the world as harsh and unkind, a place call- ing for protective vigilance and mistrust.

According to the DSM-IV-TR, which diagnostic criterion describes schizotypal personality disorder? 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. 3. Considers relationships to be more intimate than they actually are. 4. Exhibits behavior or appearance that is odd, eccentric, or peculiar.

4 Magical thinking and odd beliefs that influence behavior and are inconsistent with subcultural norms are defined as cri- teria for schizotypal personality disorder, which is often described as "latent schizophrenia." Clients with this diagnosis are odd and eccentric, but do not decom- pensate to the level of schizophrenia.

A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count

4 Rationale: A client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 cells/mm3. Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.

A client gives the home health nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate less than 60 beats/minute 4. Frequent hand-washing with hot soapy water

4 Rationale: Clomipramine (Anafranil) is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Sedation sometimes occurs. Insomnia seldom is a side effect. Weight gain and tachycardia are side/adverse effects of this medication.

The nurse is administering risperidone (Risperdal) to a client who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight. 2. Continue driving as usual. 3. Avoid foods rich in potassium. 4. Get up slowly when changing positions.

4 Rationale: Risperidone (Risperdal) can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. With any psychotropic medication, caution needs to be taken (such as with driving or other activities requiring alertness) until the individual can determine whether his or her level of alertness is affected. Food interaction is not a concern.

The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."

4 Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse should ask the client whether he or she has intentions to hurt him- or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness, but are not specific interventions for hallucinations, if they occur.

A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client? 1. If the client exhibits a developmental disorder, such as autism. 2. If the client has a medical condition that could contribute to the symptoms. 3. If the client experiences manic or depressive signs and symptoms. 4. If the client's signs and symptoms last for 6 months.

4 The client's signs and symptoms lasting for 6 months is further evidence for the diagnosis of schizophrenia. Two or more characteristic symptoms must be present for a significant amount of time during a 1-month period and must last for 6 months to meet the criteria for the diagnosis of schizophrenia.

The nurse is evaluating lab test results for a client prescribed lithium carbonate (lithium). The client's lithium level is 1.9 mEq/L. Which nursing intervention takes priority? 1. Give next dose because the lithium level is normal for acute mania. 2. Hold the next dose, and continue the medication as prescribed the following day. 3. Give the next dose after assessing for signs and symptoms of lithium toxicity. 4. Immediately notify the physician, and hold the dose until instructed further.

4 The nurse needs to notify the physician immediately of the serum level, which is outside the therapeutic range, to avoid any risk for further toxicity. *0.6-1.2***

A nurse is assessing a client in the mental health clinic 6 months after the client's dis- charge from in-patient psychiatric treatment for schizophrenia. The client has no active symptoms, but has a flat affect and has recently been placed on disability. What should the nurse document? 1. "The client is experiencing symptoms of the schizoid personality phase of the devel- opment of schizophrenia." 2. "The client is experiencing symptoms of the prodromal phase of the development of schizophrenia." 3. "The client is experiencing symptoms of schizophrenia." 4. "The client is experiencing symptoms of the residual phase of the development of schizophrenia."

4. Symptoms during the residual phase are similar to those of the prodromal phase, with flat affect and impairment in role function being prominent. This client has recently experienced an active phase of schizophrenia and has been placed on dis- ability, indicating problems with role functioning. The nurse would recognize the symptoms presented as an indication that the client is in the residual phase of schizophrenia

For the past year, a client has received haloperidol (Haldol). The nurse administering the client's next dose notes a twitch on the right side of the client's face and tongue movements. Which nursing intervention takes priority? 1. Administer haloperidol (Haldol) along with benztropine (Cogentin) 1 mg IM PRN per order. 2. Assess for other signs of hyperglycemia resulting from the use of the haloperidol (Haldol). 3. Check the client's temperature, and assess mental status. 4. Hold the haloperidol (Haldol), and call the physician.

4. The symptoms noted in the question reflect tardive dyskinesia, and the nurse must hold the medications to avoid permanent damage and call the physician.

When assessing a client diagnosed with histrionic personality disorder, the nurse might identify which characteristic behavior? 1. Odd beliefs and magical thinking. 2. Grandiose sense of self-importance. 3. Preoccupation with orderliness and perfection. 4. Attention-seeking flamboyance

4. Clients diagnosed with histrionic person- ality disorder have a pervasive pattern of excessive emotionality and attention- seeking behaviors. These individuals are uncomfortable in situations in which they are not the center of attention and have a style of speech that is excessively impres- sionistic and lacking in detail.

The nurse documents that a client diagnosed with a thought disorder is experiencing anticholinergic side effects from long-term use of thioridazine (Mellaril). Which symp- toms has the nurse noted? 1. Akinesia, dystonia, and pseudoparkinsonism. 2. Muscle rigidity, hyperpyrexia, and tachycardia. 3. Hyperglycemia and diabetes. 4. Dry mouth, constipation, and urinary retention.

4. Dry mouth, constipation, and urinary retention are anticholinergic side effects of antipsychotic medications such as thioridazine (Mellaril). Anticholinergic side effects are caused by agents that block parasympathetic nerve impulses. Thioridazine (Mellaril) has a high inci- dence of anticholinergic side effects.

A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior patterns would the nurse expect to observe? 1) Socially isolates 2) Exhibits entitled behaviors 3) Has bizarre speech patterns 4) Generates conflict among the staff

4: Clients diagnosed with borderline personality disorder, having little empathy toward others, are unable to accept both positive and negative feelings and view others as all good or all bad. They tend to split staff, generating conflict

A suicidal client diagnosed with borderline personality disorder exhibits both fear and anger during the intake interview. Which nursing intervention would be appropriate for this client? 1) Confine the client to a single room to promote calmness. 2) Medicate client with antipsychotic medication to decrease fear and anger. 3) Within 7 days, client will verbalize strategies to interrupt escalation of fear and anger. 4) Start supportive counseling to identify sources of anger.

4: A client diagnosed with a borderline personality disorder often displaces negative feelings onto the staff, resulting in countertransference and splitting. Countertransference refers to the nurse's emotional and behavioral response to the client. Splitting is the inability of the client to accept both positive and negative feelings about others, viewing them as all good or all bad. Identifying the client's source of anger through supportive counseling may help decrease splitting, countertransference, and any resulting conflict.

Which statement is true about vascular neurocognitive disorder? 1) Vascular neurocognitive disorder is reversible. 2) Vascular neurocognitive disorder is characterized by plaques and tangles in the brain. 3) Vascular neurocognitive disorder involves a gradual, progressive cognitive deterioration. 4) Vascular neurocognitive disorder involves a variable pattern of cognitive functioning.

4: In vascular neurocognitive disorder, clients suffer the equivalent of small strokes that destroy many areas of the brain. The pattern of deficits is variable, depending on which regions of the brain have been affected.

Based on the public health model of primary level of prevention, which services would the community nurse provide? 1) Teaching recovering clients daily living skills and encouraging independence 2) Monitoring effectiveness of after-care services through home health visits 3) Ongoing assessment of individuals at high risk for illness exacerbation 4) Teaching parenting skills and child development to prospective new parents

4: Primary-level prevention services are aimed at reducing the incidence of mental disorders within the population. Teaching parenting skills and child development to prospective new parents is an example of a primary level of prevention.

A client is being discharged on haloperidol (Haldol). Which teaching should the nurse include about the medication? 1) "If you forget to take your morning dose of Haldol, double the dose at bedtime." 2) "Limit your alcohol intake to no more than 3 oz. per day." 3) "When you go home, sit outside and enjoy the sunshine." 4) "Do not stop taking Haldol abruptly."

4: The client should be taught not to stop taking Haldol abruptly after long-term use. To do so might produce withdrawal symptoms, such as nausea, vomiting, dizziness, gastritis, headache, tachycardia, insomnia, and/or tremulousness.

A client diagnosed with a personality disorder is cold, aloof, and avoids others on the unit. The nurse recognizes that this behavior is symptomatic of which personality disorder? a) Schizoid personality disorder b) Dependent personality disorder c) Borderline personality disorder d) Antisocial personality disorder

A Schizoid personality disorder

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected? a) "It's not my fault." b) "I'm too ashamed to talk about it." c) "I just don't remember doing it." d) "I'm really sorry about all the people I've hurt."

A. Individuals diagnosed with antisocial personality disorders lack remorse about their actions and view themselves as victims. This individual would most likely refuse to acknowledge responsibility for the accident.

When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior? a) Odd beliefs and magical thinking b) Grandiose sense of self-importance c) Pattern of intense and chaotic relationships d) Submissive and clinging behaviors

B Clients diagnosed with narcissistic personality disorder have an exaggerated sense of self-worth. They are often grandiose and believe they have an inalienable right to receive special consideration.

In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe? a) Predictability b) Controlled anger c) Little tolerance for being alone d) Stable and satisfactory relationships

C Clients diagnosed with borderline personality disorder have little tolerance for being alone. They prefer a frantic search for companionship, no matter how unsatisfactory, rather than experiencing feelings of loneliness, emptiness, and boredom