Mental Health HESI Review Questions

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal

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

The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A. "I'm not very pretty or likeable." B. "I've lost 20 pounds in the past month." C. "I like to keep things to myself." D. "I think everyone is out to get me."

ANS: A Rationale: Feelings of hopelessness are characteristics of one who is depressed. Although option B might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. Options C and D are indicative of a paranoid personality.

The client takes selective serotonin reuptake inhibitors (SSRIs) for depression. What new problem should prompt the nurse to evaluate the client for serotonin syndrome? 1.Fever 2.Bradycardia 3.Suicidal ideation 4.Sexual dysfunction

ANS:1 Rationale: Serotonin syndrome is a potentially life-threatening medication reaction that causes the body to have too much serotonin, a chemical produced by nerve cells. High fever is a typical characteristic associated with serotonin syndrome. It will cause tachycardia, rather than bradycardia. Both sexual dysfunction and suicidal ideation are adverse effects of SSRIs, but are not associated with serotonin syndrome.

Questions the nurse could ask that would be nonjudgmental when obtaining information about a client's use of complementary and herbal remedies include (Select all that apply): a. "You don't regularly take herbal remedies, do you?" b. "What herbal medicines have you used to relieve your symptoms?" c. "What over-the-counter medicines, vitamins, and nutritional supplements do you use?" d. "What differences in your symptoms do you notice when you take herbal supplements?" e. "Have you experienced problems from using herbal and prescription drugs at the same time?"

Correct answer: B, C, D, E The correct responses are neutral in tone and do not express bias for or against the use of complementary or herbal medicines. The distracter, worded in a negative way, makes the nurse's bias evident.

An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? A) You are in the hospital, and I am the nurse caring for you. B) It must be difficult for you to control your anxious feelings. C) Go to occupational therapy and start a project. D) You are not in a war area now; this is the United States.

Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others (C). Delusions are often well-fixed, and though (A) reinforces reality, it is argumentative and dismisses the client's fears. It is often difficult for the client to recognize the relationship between delusions and anxiety (B), and the nurse should reassure the client that he is in a safe place. Dismissing delusional thinking (D) is unrealistic because neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy. Correct Answer(s): C

A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. The nurse knows that the client is using which defense mechanism? A) Sublimation. B) Identification. C) Introjection. D) Repression.

Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or memories from one's awareness. Correct Answer(s): B

A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment? A) I will die if my cat dies. B) I don't feel like eating this morning. C) I just went to my friend's funeral. D) Don't you have more important things to do?

Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. Normal grief process differs from depression, and at this client's age peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood levels which would negate suicide ideation at this time. Correct Answer(s): A

The nurse is preparing to care for a woman victimized by physical abuse. The nurse should plan to perform which action first? 1.Support the woman, and facilitate access to a safe environment. 2.Talk to the woman about how and why the abuser became provoked. 3.Reinforce that dealing with the psychological aspects is of the highest priority. 4.Establish firm time lines for the woman to make necessary changes in her life situation.

ANS: 1 Rationale: The nurse must provide emotional support to the client and provide measures to ensure a safe environment. Option 2 fosters the notion that the client is at fault. In options 3 and 4, the nurse may be making unreasonable demands, which could cause further distress for the client.

The nurse is creating a plan of care for a client with mania and determines that the client is experiencing disturbed thoughts. Which activity related to disturbed thoughts should the nurse provide for the client initially? 1.Painting 2.Playing cards 3.Playing checkers 4.Playing a board game

ANS: 1 Rationale: When the client is manic, solitary activities requiring a short attention span or mild physical exertion activities, such as writing, painting, finger-painting, woodworking, or walks with the staff, are best initially. Solitary activities minimize stimuli, and mild physical activities release tension constructively. When less manic, the client may join 1 or 2 other clients in quiet nonstimulating activities. Competitive games should be avoided because they can stimulate aggression and cause increased psychomotor activity.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions

ANS: 2 Rationale: Buspirone is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone most often is indicated for the treatment of anxiety.

A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright

ANS: 2 Rationale: Seizure activity can occur in clients taking bupropion dosages greater than 450 mg daily. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. This medication does not cause significant orthostatic blood pressure changes.

A client's medication sheet contains a prescription for sertraline. 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

ANS: 2 Rationale: Sertraline is classified as an antidepressant. Sertraline 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 is not prescribed for use as needed.

A client diagnosed with schizophrenia has been prescribed clozapine. The nurse should monitor the client for which side/adverse effects of this medication? Select all that apply. 1.Diarrhea 2.Sedation 3.Dry mouth 4.Weight loss 5.Orthostatic hypotension 6.Presence of a fixed stare

ANS: 2,3,5,6 Rationale: Clozapine is an antipsychotic medication used to treat schizophrenia. Hallucinations, delusions, and altered thought processes are characteristic of this disorder and should decrease with effective treatment. Fixed stare, dry mouth, orthostatic hypotension, and sedation are side/adverse effects of therapy. The other options are unrelated to this medication.

A client has a lithium level of 2.4 mEq/L. The nurse should immediately assess the client for which sign or symptom? 1.Diarrhea 2.Weakness 3.Blurred vision 4.Cardiac dysrhythmias

ANS: 3 Rationale: At lithium levels of 2.0 to 2.5 mEq/L the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2.0 mEq/L the client experiences vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3.0 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.

A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for the past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.

ANS: 3 Rationale: Depressed individuals sleep for long periods, are unable to go to work, and feel as if they cannot "do anything." When these clients have had some therapeutic effect from their medication, they report resolution of many of these complaints and exhibit an improvement in their appearance. Options 1, 2, and 4 identify continued depression.

A hospitalized client is started on phenelzine 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 6. Oatmeal raisin cookies

ANS: 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 middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask? A. "Are you taking prescribed antidepressants?" B. "How much alcohol do you consume daily?" C. "What seems to precipitate the anxious feelings?" D. "How many hours do you sleep per day?"

ANS: B Rationale: First, and most importantly, the client's use of alcohol should be determined because further treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed is a better question than asking if the client is drinking, which is a "yes-no" answer that does not promote dialogue. Options A, C, and D provide worthwhile assessment data, but first the nurse should determine if the client is still drinking because all efforts to treat symptoms associated with depression are diminished if the client is still consuming alcohol.

A client is being treated for anorgasmia. Which assessment question demonstrates that the nurse understands the likely causes of the disorder? 1."How would you feel if you became pregnant?" 2."When did you have your first menstrual period?" 3."Do you feel you eat a well-balanced, nutritious diet?" 4."Does depression seem to affect members of your family?"

ANS:1 Rationale: Anorgasmia is the medical term for persistent difficulty reaching an orgasm after sexual stimulation. Anorgasmia is generally psychological in its cause. Dread of pregnancy is a common fear that can result in this disorder. A poor diet, onset of menses, and the presence of familial depression are not known factors in the development of this disorder.

The nurse suspects that a client prescribed clomipramine hydrochloride has been noncompliant with taking the medication as prescribed. Which client behavior would support the nurse's suspicion? 1.Tired, fatigued appearance 2.Complaints of hunger and fatigue 3.Frequently checking for the car key 4.Slight dizziness when standing up quickly

ANS:3 Rationale: Clomipramine is an antidepressand that is commonly used in the treatment of obsessive-compulsive disorder. Frequent checking for the car key is a nonproductive repetitive activity that is characteristic of this disorder. Reappearance of symptoms may indicate noncompliance with medication therapy. The incorrect options are common side/adverse effects of the medication.

When should the nurse advise a client being prescribed fluoxetine hydrochloride to take the medication? 1.Just before bedtime 2.With the evening meal 3.At noon with an antacid 4.In the morning on first arising

ANS:4 Rationale: Fluoxetine hydrochloride is an antidepressant and is administered in the early morning so that the client will experience an elevated mood during the daytime hours. In addition, fluoxetine can cause insomnia so taking the medication early in the day will prevent interference with sleep. The other options are incorrect.

A client diagnosed with schizophrenia is taking haloperidol. The nurse understands that this medication will exert its therapeutic effect through which mechanism? 1.Blocking serotonin reuptake 2.Inhibiting the breakdown of released acetylcholine 3.Blocking the uptake of norepinephrine and serotonin 4.Blocking dopamine from binding to postsynaptic receptors in the brain

ANS:4 Rationale: Haloperidol is an antipsychotic. Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Fluoxetine hydrochloride is a potent serotonin reuptake blocker. Donepezil hydrochloride inhibits the breakdown of released acetylcholine. Imipramine hydrochloride blocks the uptake of norepinephrine and serotonin.

Which assessment finding would the nurse anticipate when monitoring a client who is at risk for developing neuroleptic malignant syndrome? 1.Dysphagia 2.Bradycardia 3.Hypotension 4.Hyperpyrexia

ANS:4 Rationale: Hyperpyrexia with body temperatures up to 107°F may be present in neuroleptic malignant syndrome (NMS). Manifestations develop suddenly and may include respiratory distress and muscle rigidity. As the condition progresses, evidence of tachycardia, hypertension, increasing respiratory distress, confusion, and delirium may appear. Dysphagia is not associated with this condition.

A nurse instructs a client taking a MAOI to avoid certain foods and drugs because of the risk of: a. Cardiac dysrhythmia b. Hypotensive shock c. Hypertensive crisis d. Hypoglycemia

Correct answer: C Clients taking MAO-inhibiting drugs must be on a low tyramine diet to prevent hypertensive crisis. In the presence of MAO inhibitors, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first? A) Do you have problems with hallucinations? B) Are you ever alone when you hear the voices? C) Has anyone in your family had hearing problems? D) Do you see things that others cannot see?

Determining if the client is alone when she hears voices (B) will assist in differentiating between hallucinations and hearing loss; this is especially important in the aging population. If the client is experiencing hallucinations, the voices will be real to her, and it is unlikely that (A) would provide accurate information. (C and D) might be good follow-up questions, but would not have the priority of (B). Correct Answer(s): B

The nurse should provide instructions concerning which side effect to a client prescribed chlorpromazine? 1.Dry mouth 2.Hand tremors 3.Lip smacking 4.Increased urinary output

ANS: 1 Rationale: Chlorpromazine is an antipsychotic medication that belongs to the phenothiazine group. Side effects of chlorpromazine can include hypotension, dizziness, and fainting, especially with parenteral use. Additional side effects include drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, nasal congestion, peripheral edema, and urinary retention. The remaining options are not associated with this medication.

The mother of a child diagnosed with attention deficit hyperactivity disorder has been given instructions about how to administer methylphenidate. Which response by the mother shows she understands the information about the best way to administer the medication? 1.At bedtime 2.After breakfast 3.At the evening meal 4.With a bedtime snack

ANS: 2 Rationale: Children with attention deficit hyperactivity disorder should take the morning dose after breakfast and the last daily dose should be taken at least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia. The other options are incorrect.

A client is prescribed imipramine once daily. The nurse determines that additional teaching is needed on the basis of which statement by the client? 1."I need to avoid alcohol while taking this medication." 2."I'll take the medication in the morning before breakfast." 3."I won't notice any medication effects for at least 2 weeks." 4."I'll be sure to take a missed medication dose as soon as possible unless it is almost time for the next dose."

ANS: 2 Rationale: Imipramine is a tricyclic antidepressant. The client should be instructed to take a single daily dose of the medication at bedtime, not in the morning, because of its side effect of sedation. The client should avoid alcohol or other central nervous system depressants during therapy. The medication effects may not be noticed for at least 2 weeks. The client should take the medication exactly as directed, but if a dose is missed the client should take it as soon as possible unless it is almost time for another dose.

The nurse is describing the medication side and adverse effects to a client who is taking oxazepam. Which information should the nurse incorporate in the discussion? 1. Consume a low-fiber diet. 2. Increase fluids and bulk in the diet. 3. Rest if the heart begins to beat rapidly. 4. Take antidiarrheal agents if diarrhea occurs.

ANS: 2 Rationale: Oxazepam causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the health care provider (HCP) is notified because this could indicate overdose. In addition, diarrhea could indicate an incomplete intestinal obstruction and, if this occurs, the HCP is notified.

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

ANS: 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 about the medication. The nurse should inform the client to expect maximum desired effects at which 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

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

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

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

A monoamine oxidase inhibitor is prescribed for a client. Which sign or symptom is indicative of toxicity? 1.Lethargy 2.Depression 3.Restlessness 4.Constipation

ANS: 3 Rationale: Acute toxicity of monoamine oxidase inhibitors (MAOIs) is manifested by restlessness, anxiety, and insomnia. Dizziness and hypertension also can occur in acute toxicity. The remaining options are not signs of toxicity related to MAOIs.

A client diagnosed with anxiety is starting therapy with lorazepam. Which factor in the client's history should prompt the nurse to consult with the health care provider before administering the medication? 1.Hypothyroidism 2.Diabetes mellitus 3.Narrow-angle glaucoma 4.Coronary artery disease

ANS: 3 Rationale: Lorazepam is a benzodiazepine and is contraindicated in hypersensitivity, cross-sensitivity with other benzodiazepines, comatose state, preexisting central nervous system depression, uncontrolled severe pain, and narrow-angle glaucoma. It also is contraindicated in pregnancy and in women who are breast-feeding. None of the other options are relevant to the administration of lorazepam.

A client with schizophrenia has been started on medication therapy with clozapine. 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

ANS: 4 Rationale: A client taking clozapine 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 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.

To determine whether the client is experiencing akathisia as an adverse effect of the medication haloperidol, what should the nurse observe the client for? 1.Lip smacking 2.Puffing of the cheeks 3.Rapid tongue movements 4.Restlessness or constant generalized movement

ANS: 4 Rationale: Akathisia is restlessness or an urge to keep moving. It may appear within 6 hours of administration of the first dose and may be difficult to distinguish from psychotic agitation. The other options describe tardive dyskinesia, which is manifested by uncontrolled rhythmic movements of the mouth, face, and extremities. These movements can include lip smacking or puckering, puffing of the cheeks, uncontrolled chewing, and the presence of rapid or undulating (wormlike) movements of the tongue.

A client gives the home health nurse a bottle of clomipramine. 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

ANS: 4 Rationale: Clomipramine 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 and adverse effects of this medication.

The nurse should assess for which toxic effect when managing the care of a client prescribed haloperidol? 1.Nausea 2.Hypotension 3.Blurred vision 4.Excessive salivation

ANS: 4 Rationale: Haloperidol is an antipsychotic medication. Toxic effects include marked drowsiness and lethargy, excessive salivation, a fixed stare, akathisia, acute dystonia, and tardive dyskinesia. Nausea, hypotension, and blurred vision are occasional side effects.

The health care provider is planning to prescribe a medication for a client with major depression. Which medication should the nurse expect to be prescribed? 1.Diazepam 2.Lorazepam 3.Phenobarbital 4.Paroxetine hydrochloride

ANS: 4 Rationale: Paroxetine is an antidepressant used in the treatment of major depression. Diazepam and lorazepam are benzodiazepines and are used to treat anxiety. Phenobarbital is a barbiturate used for the short-term treatment of insomnia.

A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. Take the medication only with meals. 2. Take the medication at the same time each day. 3. Use a dose container to help prevent missed doses. 4. Avoid drinking alcohol while taking this medication.

ANS: 4 Rationale: Phenobarbital is an anticonvulsant and hypnotic agent. The client should avoid taking any other central nervous system depressants such as alcohol while taking this medication. The medication may be given without regard to meals. Taking the medication at the same time each day enhances compliance and maintains more stable blood levels of the medication. Using a dose container or "pillbox" may be helpful for some clients.

The nurse is administering risperidone 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.

ANS: 4 Rationale: Risperidone 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.

A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on the client's complaints? A. Enroll the client in an exercise class to promote positive activities. B. Place a lock on the client's closet to allay the client's concerns. C. Promote extinction of the ideation by ignoring the client. D. Explain to the client that these suspicions are certainly false.

ANS: A Rationale: Diverting the client's attention from paranoid ideation and encouraging the client to engage in positive activities can be helpful in assisting to develop a positive self-image. Option B actually supports paranoid ideation. Option C may lower self-esteem. The nurse should not argue with the client about the delusions (option D).

The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal? A. Psychomotor agitation B. Restlessness and hyperactivity C. Detachment from reality and drowsiness D. Distorted perceptions and hallucinations

ANS: A Rationale: During cocaine withdrawal, the nurse should expect option A and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. Options B, C, and D are signs and symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal from cocaine.

A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet."

ANS: A Rationale: Option A is the best choice because the nurse does not argue with the client or demand that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. Options B and C are challenging the client's delusions, and option B asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. Option D has not addressed the actual problem—that is, the client's delusions.

A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching? A. "I am going to have lots of fun at the beach and plenty of time in the sun." B. "While I am on vacation, I will not eat or drink anything that contains alcohol." C. "I will notify the health care provider if I have a sore throat or flulike symptoms." D. "I will continue to take my benztropine mesylate every day."

ANS: A Rationale: Photosensitivity is a side effect of fluphenazine decanoate, so the client should be instructed to avoid the sun. Options B, C, and D indicate accurate knowledge. Alcohol acts synergistically with fluphenazine decanoate. A sore throat and flulike symptoms are signs of agranulocytosis, which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with fluphenazine decanoate.

The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? A. The child will be protected from further harm. B. The family's cultural values will be respected. C. The parents will express regret at harming their child. D. The parents will demonstrate an ability to care for burn wounds.

ANS: A Rationale: The nurse's highest priority is to ensure that no further harm befalls the child. Options B, C, and D are also important objectives but are secondary to option A.

The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record? A. Liver function test results B. Creatinine clearance C. Complete blood count D. Chemistry panel

ANS: A Rationale: Valproic acid is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests should be included in the client's record. Option B should be in the client record of those who are receiving lithium because it is excreted by the kidneys. Options C and D are routine laboratory tests and are not specifically related to administration of valporic acid.

A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam. When developing the nursing care plan for this client, which intervention would be most important for the nurse to include? A. Assist client to focus on personal strengths. B. Set limits on self-defacing comments. C. Remind the client of daily activities in the milieu. D. Assist the client to identify why he or she was self-destructive.

ANS: A Rationale: Encouraging the client to focus on his or her strengths helps the client become aware of positive qualities, assists in improving self-image, and aids in coping with past and present situations. Although nursing actions should assist the client in decreasing self-defacing comments and informing the client of daily activities in the milieu, these interventions are not priorities at this time. Option D is not as important as assisting the client to overcome the depression, which resulted in the overdose, and asking "why" is not therapeutic.

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make? A. "How can I help you? Tell me more about your problems." B. "Things probably aren't as bad as they seem right now." C. "Let's talk about what is right with your life." D. "I hear your misery, but things will get better soon."

ANS: A Rationale: Offering self shows empathy and caring and gives the client the opportunity to talk while the nurse listens. Option B dismisses the client's perception that things are really bad and potentially stops further communication with the client. Option C avoids the client's problems and promotes denial. "I hear your misery" is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence, "but things will get better soon," which offers false reassurance.

A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements.

ANS: A Rationale: Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise. Option B is important with lithium, a mood stabilizer. Options C and D are less common than weight gain.

The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? A. Greet the client by first name during each social interaction. B. Determine if the client is experiencing auditory hallucinations. C. Introduce the client to peers on the unit as soon as possible. D. Assign the client to a group about developing social skills.

ANS: A Rationale: The most important nursing intervention is to greet the client by name and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions, but option B is not a priority intervention. Options C and D are effective interventions after individual rapport has been established with the client.

When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.) A. Oxygen B. Suction equipment C. Continuous passive range-of-motion (CPM) machine D. Crash cart E. Chest tube drainage system

ANS: A,B,D Rationale: Because aspiration is a potential complication, emergency equipment such as oxygen, suction, and a crash cart should be available (A, B, and D). The client is only unconscious for a short period; therefore, there is no need for a CPM machine (C). ECT does not put the client at risk for a pneumothorax; therefore, a chest tube drainage system is not needed (E).

A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.) A. Sleepwalking B. Unable to remember who he is C. Has recurrent intrusive obsessions D. Acute attack of anxiety E. Exhibits multiple personalities

ANS: A,B,E Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness and are consistent with a diagnosis of dissociative disorder (A,B,E). (C) is consistent with obsessive-compulsive disorder. (D) is associated with neuro-cognitive disorders.

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) A. Importance of adherence to medication regimen B. Current treatment measures for substance abuse C. Signs and symptoms of an exacerbation D. Prevention of criminal activity E. Behavior modification for aggression F. Chronic grief associated with long-term illness

ANS: A,C,F Rationale: Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.

A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? A. Sublimation B. Identification C. Introjection D. Repression

ANS: B Rationale: Identification is an attempt to be like someone or emulate the personality traits of another. Option A is substituting an unacceptable feeling with one that is more socially acceptable. Option C is incorporating the values or qualities of an admired person or group into one's own ego structure. Option D is the involuntary exclusion of painful thoughts or memories from one's awareness.

A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client? A. A 35-year-old client who recently attempted suicide B. A manic client who has started lithium carbonate treatment C. A client who is bipolar and is pacing the floor while telling jokes to everyone D. A paranoid client who believes that the staff is trying to poison the food

ANS: B Rationale: Option B appears to be the most stable client described since treatment was begun with lithium carbonate (treatment of choice for manic depression). Being around another depressed individual might enhance this client's own depression and possibly support suicidal ideation. Clients in the manic stage of bipolar disease enhance the level of anxiety of those around them, which would not be therapeutic for the client at this time. Paranoid ideation, which is characterized by suspiciousness, would also increase anxiety in this client.

A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection." B. "I know these treatments must seem like torture to you, but we want to help you recover." C. "You have so much to live for, and all of your family members want you to live." D. "Would you like me to call the chaplain so that you can discuss your feelings privately?"

ANS: B Rationale: Options B offers an empathetic response without sounding patronizing. Options A is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. Option C appears as scolding and places blame on the client for wanting to die and possibly hurting the client's family members as a result. Option D might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment.

An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes his/her body to other residents. Which intervention should the nurse implement? A. Establish a one-to-one relationship to discuss the behavior. B. Redirect the client to physically demanding activities. C. Encourage the client to verbalize thoughts when acting out. D. Restrict social interactions with other residents in the facility.

ANS: B Rationale: The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect the client to activities that are physically demanding so that energy can be expended in a socially acceptable manner. Psychotic clients are not capable of option A. When exhibiting acting-out behavior, the client is distracted and option C is difficult. Option D is likely to increase manic behaviors, such as mood swings and acting-out behaviors.

The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? A. Tries to interact with a few peers and staff. B. Reports feeling better and less depressed. C. Sits attentively with peers in group therapy. D. Easily awakens for morning medications.

ANS: B Rationale: The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed. The client may interact with peers and staff and sit attentively in groups without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening is not an indication of improvement.

Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first? A. Remind the client to wear the nicotine patch. B. Determine if the client still needs constant observation. C. Encourage the client to attend the smoking cessation group. D. Explain that clients on constant observation cannot smoke.

ANS: B Rationale: The nurse should continually reassess the need for constant observation so that the client can have unit privileges such as outdoor breaks. Options A and C do not meet the client's need and desire to smoke. Option D will cause more agitation.

A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A. Place the client on seizure precautions and monitor frequently. B. Take the client's vital signs and notify the health care provider immediately. C. Describe the symptoms to the charge nurse and document them in the client's record. D. No action is required at this time because these are known side effects of the medications.

ANS: B Rationale: This is an emergency situation, and the client requires immediate management in a critical care setting. These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. Option A is not indicated in this situation. Option C does not consider the seriousness of the situation. Option D is an incorrect statement.

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take? A. Notify the health care provider immediately and force fluids. B. Prior to giving the next dose, notify the health care provider of these symptoms. C. Record the symptoms and continue with medication as prescribed. D. Hold the medication and refuse to administer additional doses.

ANS: B Rationale: Although these are expected symptoms, the health care provider should be notified prior to the next administration of the drug. Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally follow a progressive pattern, beginning with diarrhea, vomiting, drowsiness, and muscular weakness (option C). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Option A will lower the lithium level. Option D is not warranted.

At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A. "Yes, I am the leader today. Would you like to be the leader tomorrow?" B. "Yes, I will be leading this group. What would you like to accomplish?" C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself."

ANS: B Rationale: Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. Option B provides information and refocuses the group to defining its function. Option A is manipulative bargaining. Option C does not focus the group on its purpose or task. Option D is interpreting the client's feelings and is almost challenging.

Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A. "I need to tell the health care provider about your child's tendency to be accident-prone." B. "Tell me more about these accidents that your child has been having." C. "I need to report these injuries to the authorities because they do not seem accidental." D. "Boys this age always seem to require more supervision and can be quite accident-prone."

ANS: B Rationale: Option B seeks more information using an open-ended, nonthreatening statement. Option A might be appropriate but is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the health care provider for resolution. Although it is true that suspected cases of child abuse must be reported, option C is almost an attack and is jumping ahead before conclusive data are obtained. Option D is a cliché and dismisses the seriousness of the situation.

The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation? A. Recently started wetting the bed. B. Joined a competitive boxing team. C. Kicks the dog after being scolded by his dad. D. Starts a student organization to ban violence.

ANS: B Rationale: Sublimation is a coping mechanism characterized by substituting an unacceptable feeling or action with a more socially acceptable one. Option A is an example of regression, Option C is characteristic of displacement, and Option D is consistent with undoing.

What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.) A. Take the medication in the morning for best results. B. Do not combine this medication with alcohol. C. This medication is typically used for short-term treatment. D. Stop the drug immediately if sleepiness occurs. E. Avoid driving or operating equipment while taking this drug.

ANS: B,C,E Rationale: Harm can occur if oxazepam is taken with alcohol or other central nervous system (CNS) depressants (B). Oxazepam is a benzodiazepine used for the short-term treatment of anxiety (C). Sleepiness is an expected side effect; therefore, driving or operating equipment should be avoided (E). The drug should be taken in the evening because of sedation effects (A) and should be tapered, not immediately stopped, because of withdrawal effects (D).

A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make? A. "Describe in more detail your feelings about being overwhelmed." B. "Why don't you give up some of your commitments?" C. "What has worked for you in the past?" D. "I know, but it is important to take time for yourself."

ANS: C Rationale: A nurse can help the client solve problems by identifying past coping mechanisms that could be transferred into current situations that the client finds to be overwhelming. The client has already expressed some degree of hopelessness (overwhelmed and anxious), so option A is redundant. Option B is advice giving and may not be possible for the person, and this response does not encourage the client to employ known methods of coping. Option D is also considered advice giving, with an implied value judgment.

Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A. Talk to the client outside the group about his behavior. B. Ask the client to give others a chance to talk. C. Allow the group to handle the problem. D. Ask the client to join another group.

ANS: C Rationale: After several weeks, the group is in the working phase, and the group members should be allowed to determine the direction of the group. The nurse should ignore the comments and allow the group to handle the situation. A good leader should not have separate meetings with group members, because such behavior is manipulative on the part of the leader. Option B is dictatorial and is not in keeping with good leadership skills. Option D is avoiding the problem. Remember, identify which phase the group is in (initial, working, or termination) as an aid to determining expected communication style.

A client believes that his health care provider is an FBI agent and that his apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to be prescribed for this client? A. Antianxiety medication B. Mood stabilizer C. Antipsychotic D. Sedative-hypnotic

ANS: C Rationale: An antipsychotic will most likely be prescribed because the client's thoughts are delusional. The client needs an antipsychotic medication to promote rational thoughts. Option A may lessen anxiety associated with the delusions, but is not the treatment of choice for altered thoughts. Option B will manage mood swings, and Option D will be prescribed for sleep.

A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food

ANS: C Rationale: Delusional clients have difficulty with trust and have low self-esteem. Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. Options A, B, and D are not specifically related to the development of delusions.

A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? A. Implementation of the goal should be deferred until further data can be gathered. B. The depression will dissipate once the client becomes accustomed to retirement. C. Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness. D. Nursing goals should be approved by the treatment team before they are initiated.

ANS: C Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings. Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be ignored. Option B dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse, although the nurse can collaborate with the treatment team.

A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take? A. Have the staff escort the client to his room. B. Tell the client that his behavior will be documented in his record. C. Redirect the client by offering an activity such as playing card games. D. Review the medication record for an antipsychotic drug.

ANS: C Rationale: Distracting the client, or redirecting him toward a constructive activity, prevents further escalation of the inappropriate behavior. Option A could result in escalating the abuse and might unnecessarily involve another staff member in the abusive situation. Option B may be more threatening to the client. Option D may be indicated if the behavior escalates, but at this time the best initial action is option C.

During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? A. "Sometimes I take an extra one of my pills when I hear the voices." B. "The voices are louder when I forget to take my medication." C. "No matter what I do, I cannot make the voices go away." D. "I just try to tell the voices to stop when they bother me."

ANS: C Rationale: Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self-harm. Option A or B does not require hospitalization unless symptoms become severe. The client should continue symptom management strategies to prevent hospitalization.

A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A. Obtain objective data such as radiographs before reporting suspicions. B. Confirm suspicions of abuse with the health care provider. C. Report any case of suspected child abuse. D. Document injuries to confirm suspected abuse.

ANS: C Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse, and notifying the nurse manager or charge nurse starts the legal reporting process. Options A, B, and D delay the first step in reporting the abuse.

A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children.

ANS: C Rationale: The best intervention is to organize care so that the client can experience rest periods. The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. Option A is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (Option B). Although option D may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission.

While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? A. Confront the client who tipped over the chair about the inconsiderate behavior. B. Dismiss the other clients from the group therapy session for a 10-minute break. C. Reinforce reality to the client on the floor and remove him to a quiet space. D. Call a security code and medicate both clients with an antianxiety drug.

ANS: C Rationale: The client who is diagnosed with PTSD is re-experiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli. Options A, B, and D do not consider the needs of these two clients at this time.

On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement? A. Provide packaged foods for the client to eat. B. Begin the client on total parenteral nutritional (TPN) therapy. C. Provide a well-balanced liquid diet for the client. D. No action is necessary because the client will eat when hungry.

ANS: C Rationale: The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. Option C is the least invasive while providing nutrition that does not argue with the client's delusion. Option A is given to those with paranoid delusions. Option B is invasive and would be used as a last resort. Option C should be tried first. This client's delusion could be life threatening and should not be ignored.

An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? A. Abdominal cramping and watery eyes B. Depression and fatigue C. Restlessness and confusion D. Hostility and anger

ANS: C Rationale: A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. Option A is indicative of withdrawal from opiates such as heroin or morphine. Option B is often seen in cocaine withdrawal. Option D is most characteristic of the paranoid client.

An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement? A. Assess the child's blood pressure. B. Counsel the child to wear cotton underwear. C. Report as suspected child abuse. D. Determine if the child takes bubble baths.

ANS: C Rationale: A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Because the child is 8 years old, the nurse should suspect child abuse and report the incident to the proper authorities. Option A is usually not related to infection. Options B and D are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection.

A client who was admitted two days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement? A. The treatment program is effective and the client is highly motivated. B. Defense mechanisms are being used to decrease anxiety. C. Manipulation is being used to achieve the client's personal goals. D. The client has insight into his behaviors, so privileges should be given.

ANS: C Rationale: Drug abusers and patients with anti-social behaviors tend to be manipulative, so option C is the best interpretation of the client's statement at this time in the client's treatment. He has been in treatment only 2 days, which is not enough time to benefit from the program, so options A and D are highly unlikely. Although defense mechanisms are frequently used to decrease anxiety, this statement is more likely because of option C.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make? A. "Did you really believe you were Jesus Christ?" B. "I think you're getting well." C. "Others have had similar thoughts when under stress." D. "Why did you think you were Jesus Christ?"

ANS: C Rationale: Option C offers support by assuring the client that others have experienced similar situations. Option A is belittling. Option B is making an inappropriate judgment. You may have narrowed your choices to options C and D. However, you should eliminate option D because it is a "why" question, and the client does not know why.

A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? A. She is regressing to an earlier behavior pattern. B. She is sublimating her anger. C. She is projecting her feelings onto the nurse. D. She is suppressing her fear.

ANS: C Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto another; it is the mother who is probably harming the child, and she is attributing her actions to the nurse. The mother may be immature, but option A is not the best description of her behavior. Option B is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (option D) by displaying anger, but such an interpretation cannot be concluded from the data presented.

A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression? A. Grandiose ideation B. Self-destructive thoughts C. Suspiciousness of others D. Negative self-image

ANS: D Rationale: A negative self-image is a specific indicator for depression. Option A occurs with paranoia or paranoid ideation. Option B may be seen in depressed clients, but not always.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? A. Each resident's length of stay at this nursing home B. A brief description of each resident's family life C. The age and medication regimen of each group member D. The usual activity patterns of each group member

ANS: D Rationale: An older person's level of activity is a determining factor in adjustment to aging as described by the activity theory of aging. All the information described in options A, B, and C might be useful to the nurse but is not as helpful during the initiation of the socialization group. The most useful initial information would be an assessment of each individual's adjustment to the aging process.

A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care? A. Schedule the client to attend various group activities. B. Reinforce the client's ability to make decisions. C. Encourage the client to identify feelings of anger. D. Provide a structured environment with little stimuli.

ANS: D Rationale: Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Noncompetitive activities that can be carried out alone should be planned for these clients. Option A is contraindicated because stimuli should be reduced as much as possible. Impulsive decision making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision-making process. Option C is more often associated with depression than with bipolar disorder.

On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders

ANS: D Rationale: Delusions are false beliefs characteristic of psychosis. Delusions are generally not characteristic of options A, B, and C.

A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you."

ANS: D Rationale: Option D is the best response because it offers support without judgment or demands. Option A is challenging the client's delusion. Option B is offering false reassurance. Option C is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse

ANS: D Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings, then the client is improving because of fewer paranoid ideas. Option A would indicate that a client with depression or one who is passive-aggressive is improving. Option B indicates feelings of paranoia. Option C indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression.

A client mumbles out loud whether anyone is talking to her or not, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement? A. Respond to the client's feelings rather than the illogical thoughts. B. Identify beliefs and thoughts about what the client is experiencing. C. Provide the client with hope that the voices will eventually go away. D. Ask the client how she has previously managed the voices.

ANS: D Rationale: The nurse should promote symptom management and determine how the client previously managed the voices. Options A and B are interventions that are useful with clients who are experiencing delusions. Option C is important, but the most important intervention is to promote symptom management.

A client prescribed thioridazine hydrochloride reports feeling faint when trying to get out of bed in the morning. The nurse recognizes this complaint as a symptom of which disorder? 1.Postural hypotension 2.Cardiac dysrhythmias 3.Psychosomatic disorder 4.Respiratory insufficiency

ANS:1 Rationale: Thioridazine hydrochloride, an antipsychotic, can cause postural hypotension. The client needs to be taught to get out of bed slowly and to rise from a sitting position slowly because of this untoward effect of the medication. None of the other options are related to this medication.

The nurse has given instructions to a client prescribed lithium carbonate. What statement by the client indicates that the client needs further information? 1."I will take the lithium with meals." 2."I will decrease fluid intake while taking the lithium." 3."Lithium blood levels must be monitored very closely." 4."I will call my health care provider if I start vomiting."

ANS:2 Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, leading to sodium depletion. A low sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa and should be taken with meals. Because therapeutic and toxic dosage ranges are narrow, lithium blood levels must be monitored closely. They are measured more frequently when the client begins the medication and then once every several months after the levels stabilize. The client should be instructed to stop taking the medication and call the health care provider if excessive diarrhea, vomiting, or diaphoresis occurs.

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client? 1.The medication is addicting. 2.Dizziness and nervousness may occur. 3.Tolerance can develop with this medication. 4.The medication can produce a sedating effect.

ANS:2 Rationale: Buspirone hydrochloride is an anxiolytic medication. Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects. Buspirone hydrochloride is not addicting, tolerance does not develop, and it is not sedating.

When a client develops neuroleptic malignant syndrome, the nurse ensures that which medication is available on the unit to address this complication? 1.Phytonadione 2.Bromocriptine 3.Protamine sulfate 4.Enalapril maleate

ANS:2 Rationale: Clients taking antipsychotic medications are at risk for neuroleptic malignant syndrome. Bromocriptine, an antiparkinsonian prolactin inhibitor, is used in the treatment of neuroleptic malignant syndrome. Phytonadione is the antidote for warfarin overdose. Protamine sulfate is the antidote for heparin overdose. Enalapril maleate is an angiotensin-converting enzyme inhibitor used to treat hypertension.

A client diagnosed with bipolar disorder is prescribed lithium carbonate. The nurse who administers the medication knows that lithium is used primarily to treat which condition? 1.Suicidal ideations 2.The manic phase of bipolar disease 3.Both depressive and manic episodes 4.The depressive phase of bipolar disease

ANS:2 Rationale: Lithium is an antimanic medication and is used to treat the manic phase of a manic-depressive disorder. The remaining options are incorrect.

The nurse taking a medication history for a client who has been admitted to the nursing unit notes that the client is receiving olanzapine. The nurse interprets that this client most likely has a history of which disorder? 1.Hypertension 2.Schizophrenia 3.Diabetes mellitus 4.Diabetes insipidus

ANS:2 Rationale: Olanzapine is an antipsychotic medication that targets both the positive and the negative symptoms of schizophrenia. The other options listed are not indications for use of this medication.

Over the course of a few hours, a client receiving lithium carbonate reports being nauseous, then drowsy and "achy." What action should the nurse take when considering the client's next scheduled dose of lithium? 1.Give the next scheduled dose and document the client's complaints. 2.Give the next scheduled dose and notify the health care provider of the client's complaints. 3.Withhold the next scheduled dose and restart the typical schedule with the next morning's dose. 4.Withhold the next scheduled dose and notify the health care provider of the client's complaints.

ANS:2 Rationale: The side/adverse effects of lithium include fine hand tremors, polyuria, mild thirst, and mild nausea. Diarrhea, vomiting, nausea, drowsiness, muscle weakness, and lack of coordination may be early signs of toxicity. The medication needs to be withheld and the health care provider notified so that the client can be further evaluated to determine the presence of toxicity. The remaining options are inappropriate actions.

A client diagnosed with bipolar mood disorder has been given a prescription for carbamazepine. The nurse teaching the client about medication side and adverse effects instructs the client to notify the health care provider if which symptom develops? 1.Nausea 2.Dizziness 3.Sore throat 4.Drowsiness

ANS:3 Rationale: Carbamazepine may be prescribed for a client with a bipolar mood disorder to provide symptomatic control of the disorder. An adverse effect of carbamazepine is blood dyscrasia. With development of a fever, sore throat, mouth ulcerations, unusual bleeding, bruising, or joint pain, the health care provider should be notified because these findings may indicate a blood dyscrasia. Nausea, dizziness, drowsiness, and vomiting are frequent side effects associated with the medication.

A client diagnosed with schizophrenia has a new prescription for risperidone. Which baseline laboratory result should the nurse review before administering the first dose of this medication? 1.Platelet count 2.Blood clotting tests 3.Liver function studies 4.Complete blood count

ANS:3 Rationale: Risperidone is an atypical antipsychotic. A baseline assessment of renal and liver function should be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level. None of the other diagnostics are relevant to this medication.

A client diagnosed with depression has a prescription for sertraline. The nurse should withhold the medication and question the prescription if the client has a history of which disorder? 1.Diabetes mellitus 2.Myocardial infarction 3.Phenelzine sulfate use 4.Irritable bowel syndrome

ANS:3 Rationale: Sertraline is a selective serotonin reuptake inhibitor. Fatal reactions may occur if sertraline is administered concurrently with phenelzine, a monoamine oxidase inhibitor (MAOI). MAOIs should be stopped at least 14 days before initiation of sertraline therapy. Likewise, sertraline should be stopped at least 14 days before initiation of MAOI therapy. The other options are incorrect.

The nurse assesses for a therapeutic effect of ziprasidone by asking the client which question? 1."Have you had more restful sleep during daytime naps?" 2."Have you experienced relief of heartburn and indigestion with meals?" 3."Have you experienced an increase in concentration during daily activities?" 4."Have you had a decrease in heart palpitations with outside physical activities?"

ANS:3 Rationale: Ziprasidone is an antipsychotic used as a mood stabilizer. The nurse should evaluate a therapeutic response by determining if the client obtained an increase in concentration. None of the remaining options are related to the use of this medication.

A client diagnosed with depression is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client's care plan should include which nursing intervention? 1.Obtain daily drug blood levels. 2.Provide the client a tyramine-free diet. 3.Assess the client for anticholinergic effects. 4.Obtain postural blood pressure prior to each medication administration.

ANS:4 Rationale: Amitriptyline hydrochloride is a tricyclic antidepressant. A common side/adverse effect is orthostatic blood pressure changes, which can produce hypotension and tachycardia. The tachycardia can be frightening to the client, and the hypotension is dangerous because it may result in dizziness and falling. The client must be instructed to move slowly from a lying to a sitting or standing position to avoid injury if these changes are experienced. The client may experience some side/adverse effects, such as sedation, dry mouth, constipation, and blurred vision (anticholinergic effects). However, these effects are transient and will diminish with time. A tyramine-free diet is initiated for a client on a monoamine oxidase inhibitor. Blood levels are required for the client taking lithium.

A client diagnosed with depression and prescribed tranylcypromine sulfate has been instructed on the appropriate diet. The nurse determines that the client understands the diet if which foods are selected from the dietary menu? 1.Pickled herring, French fries, and milk 2.Pepperoni pizza, salad, and a cola drink 3.Roasted chicken, roasted potatoes, and beer 4.Fried haddock, baked potato, and a cola drink

ANS:4 Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. A tyramine-restricted diet is required while on this medication to avoid hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausage (salami, pepperoni, bologna). In addition, figs; bananas; aged cheese; yogurt and sour cream; beer, red wine, and other alcoholic beverages; soy sauce; yeast extract; chocolate; caffeine; and aged, pickled, fermented, or smoked foods need to be avoided.

The laboratory report for a client taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3. Select the nurse's best action. a. Report the results to the health care provider immediately. b. Administer the next dose as prescribed. c. Give aspirin and force fluids. d. Repeat the laboratory test.

Correct answer: A These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider, and the drug should be withheld. The health care provider may repeat the test, but in the meantime, the drug should be withheld. (Note: This question requires the application of previous learning regarding normal and abnormal values of white blood cell counts.)

Which instruction has priority when teaching a client about clozapine (Clozaril)? a. "Avoid unprotected sex." b. "Report sore throat and fever immediately." c. "Reduce foods in polyunsaturated fats." d. "Use over-the-counter preparation for rashes."

Correct answer: B Clozapine therapy may produce agranulocytosis; therefore, signs of infection should be immediately reported to the health care provider. In addition, the patient should have white blood cell levels measured weekly. The other options are not relevant to clozapine.

By which mechanism do SSRI medications improve depression? a. Destroying increased amounts of serotonin b. Making more serotonin available at the synaptic gap c. Increasing production of acetylcholine and dopamine d. Blocking muscarine and á1 norepinephrine receptors

Correct answer: B Depression is thought to be related to lowered availability of the neurotransmitter serotonin. SSRIs act by blocking reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. SSRIs prevent destruction of serotonin. SSRIs have little or no effect on acetylcholine and dopamine production. SSRIs do not produce muscarinic or á1 norepinephrine blockade.

A nurse caring for a patient taking an SSRI will develop outcome criteria related to: a. Coherent thought processes b. Improvement in depression c. Reduced levels of motor activity d. Decreased extrapyramidal symptoms

Correct answer: B SSRIs affect mood, relieving depression in many cases. SSRIs do not act to reduce thought disorders. SSRIs reduce depressive symptoms but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

Consider these medications: carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin). Which medication below also belongs to this group? a. galantamine (Razadyne) b. valproate (Depakote) c. buspirone (Buspar) d. tacrine (Cognex)

Correct answer: B The medications listed in the stem are mood stabilizers, anticonvulsant types. Valproate (Depakote) is also a member of this group. The distracters are drugs for treatment of Alzheimer's disease and anxiety.

A client diagnosed with bipolar disorder displays aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group? a. Psychostimulants b. Mood stabilizers c. Anticholinergics d. Antidepressants

Correct answer: B The symptoms describe mania, which is effectively treated by mood stabilizers, such as lithium, and selected anticonvulsants (carbamazepine, valproic acid, and lamotrigine). Drugs from the other classifications listed are not effective in the treatment of mania.

A client is hospitalized for severe major depressive disorder. Of the medications listed below, the nurse can expect to provide the client with teaching about: a. chlordiazepoxide (Librium) b. clozapine (Clozaril) c. sertraline (Zoloft) d. Tacrine (Cognex)

Correct answer: C Sertraline (Zoloft) is an selective serotonin reuptake inhibitor (SSRI). This antidepressant blocks the reuptake of serotonin, with few anticholinergic and sedating side effects. Clozapine is an antipsychotic. Chlordiazepoxide is an anxiolytic. Tacrine treats Alzheimer's disease.

A client tells the nurse, "My doctor prescribe paroxetine (Paxil) for my depression. I assume I'll have side effects like I had when I was taking imipramine (Tofranil)." The nurse's reply should be based on the knowledge that paroxetine is a(n): a. Selective norepinephrine reuptake inhibitor b. Tricyclic antidepressant c. Monoamine oxidase (MAO) inhibitor d. SSRI

Correct answer: D Paroxetine is an SSRI and will not produce the same side effects as imipramine, a tricyclic antidepressant. The patient will probably not experience dry mouth, constipation, or orthostatic hypotension.

A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the client about medication from which group? a. Tricyclic antidepressants b. Antipsychotic drugs c. Mood stabilizers d. Benzodiazepines

Correct answer: D Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Mood stabilizers are used to treat bipolar disorder. Antipsychotic drugs are used to treat psychosis

A nurse prepares to administer a second-generation antipsychotic medication to a client diagnosed with schizophrenia. Additional monitoring for adverse effects will be most important if the client has which co-morbid health problems? (Select all that apply) a. Parkinson's disease b. Grave's disease c. Hyperlipidemia d. Osteoarthritis e. Diabetes

Correct answers: A, C, E Antipsychotic medications may produce weight gain, which would complicate care of a patient with diabetes, and increase serum triglycerides, which would complicate care of a patient with hyperlipidemia. Parkinson's disease involves changes in transmission of dopamine and acetylcholine, so these drugs would also complicate care of this patient. Osteoarthritis and Grave's disease should have no synergistic effect with this medication.

The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) A) Permit rest periods as needed. B) Speaking slowly and simply. C) Place the client on suicide precautions. D) Allow the client extra time to complete tasks. E) Observe and encourage food and fluid intake. F) Encourage mild exercise and short walks on the unit

(A, B, D, E, and F) should be included in this client's plan of care because these measures promote the client's comfort and well-being. Neurovegetative symptoms accompany the mood disorder of depression and include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. Suicidal ideation (C) does not usually accompany the neurovegetative state because the client does not have the energy or high level of anxiety associated with a suicide attempt. Correct Answer(s): A, B, D, E, F

Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A) I need to inform the healthcare provider about your child's tendency to be accident prone. B) Tell me more specifically about your child's accidents. C) I must report these injuries to the authorities because they do not seem accidental. D) Boys this age always seem to require more supervision and can be quite accident prone.

(B) seeks more information using an open ended, non-threatening statement. (A) could be appropriate, but it is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the healthcare provider for resolution. Although it is true that suspected cases of child abuse must be reported, (C) is virtually an attack and is jumping to conclusions before conclusive data has been obtained. (D) is a cliché and dismisses the seriousness of the situation. Correct Answer(s): B

The nurse is leading a "current events group" with chronic psychiatric clients. One group member states, "Saddam Hussein was my nurse during my last hospitalization. He was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make? A) Saddam Hussein was not your nurse. B) What did he do to you that was so mean? C) I didn't know that Saddam Hussein was a nurse. D) I agree that Saddam Hussein is not a very nice man.

(D) presents the reality of the situation (the individual is not nice) in relation to American culture. The fact that Saddam Hussein is not a nurse should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Correct Answer(s): D

The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions? A) The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. B) The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. C) The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. D) The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

(D) provides the most validation. The parent's explanation (subjective data) is incompatible with the objective data (small round burns on the legs and trunk). (A) provides only subjective data, and the child's explanation could be influenced by factors such as age, fear, or imagination. The parent's apparent lack of concern (B) is inconclusive, but the nurse's opinion of the parents' reaction is subjective and could be wrong. (C) might provide a clue that child abuse occurred, but the nurse must remember that most parents are anxious about their child being hospitalized. Correct Answer(s): D

The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? A) Menstruation onset at age 9. B) Contraceptive method includes condoms only. C) Menstrual cycle occurs every 35 days. D) Black-out after one drink last night on a date.

A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of the experiences or one's behavior and is indicative of high blood alcohol levels, but the client's experience of a "black-out" after one drink (D) is suspicious of the client receiving a "date rape" drug (Flunitrazepam) and needs additional follow-up. Although (A and C) occur on the outer ranges of "average," both are within acceptable or "normal" ranges. (B) is an individual preference, but using condoms as the only contraceptive method carries a higher chance of conception. Correct Answer(s): D

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make? A) My mouth feels like cotton. B) That stuff gives me indigestion. C) This pill gives me diarrhea. D) My urine looks pink.

A dry mouth (A) is an anticholinergic effect that is an expected side effect of MAO inhibitors such as phenelzine sulfate (Nardil). (B, C, and D) are not expected side effects of this medication. Correct Answer(s): A

A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa? 1.Increasing potassium-rich foods in the daily diet 2.Adding fiber to the diet to help minimize constipation 3.Medicating the client for migraine headaches as they occur 4.Monitoring the client for signs of developing contact dermatitis

ANS: 1 Rationale: In bulimia nervosa, potassium depletion and the resulting hypokalemia are often a result of the characteristic self-induced vomiting and laxative or diuretic abuse. This situation can initially be addressed with changes to the diet that increase potassium ingestion. The other options are not commonly associated with bulimia nervosa.

A client says to the nurse, "Ever since my wife passed on, my life is empty and has no meaning." What is the appropriate nursing response? 1."Your life has no meaning?" 2."Most people who lose a loved one feel empty." 3."What would your children think if they knew how you felt?" 4."Let's talk about the positive things that you have in your life."

ANS: 1 Rationale: In the correct option, the nurse uses the therapeutic technique of restating. In this technique, the nurse explores more thoroughly topics that are significant to the client. Option 2 generalizes and does not focus on the client. Option 3 focuses on the client's children rather than on the client's feelings. Option 4 avoids the client's feelings.

A client is scheduled for electroconvulsive therapy (ECT). The client says to the nurse, "I am so afraid that it will hurt and will make me worse off than I am." The nurse should make which best statement to the client? 1."Can you tell me what you understand about the procedure?" 2."Your fears are a sign that you really should have this procedure." 3."Try not to worry. This is a well-known and easy procedure for the doctor." 4."Those are very normal fears, but please be assured that everything will be okay."

ANS: 1 Rationale: The correct option is a therapeutic communication technique that explores the client's feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 diminishes the client's feelings by directing attention away from the client and to the doctor's importance. Option 4 does not address the client's fears and puts the client's feelings on hold.

The nurse helps a client with a diagnosis of obsessive-compulsive disorder prepare for bed. One hour later, the client calls the nurse and says he is feeling anxious and asks the nurse to sit and talk for a while. The nurse should take which most appropriate action? 1.Sit and talk with the client. 2.Ask the client if he would like an antianxiety medication. 3.Unlicensed assistive personnel (UAP) to sit with the client. 4.Tell the client that it is time for sleep and that they will talk tomorrow.

ANS: 1 Rationale: The most appropriate nursing action is to sit and talk if the client is expressing anxiety. Antianxiety medication may be necessary, but this is not the most appropriate nursing action. A UAP may not be able to alleviate the client's anxiety. Option 4 is an inappropriate action and places the client's feelings on hold.

A client with depression is taking tranylcypromine. The nurse should teach the client to avoid eating which food? 1.Figs 2.Pork 3.Steak 4.Chicken

ANS: 1 Rationale: Tranylcypromine is a monoamine oxidase (MAO) inhibitor. Clients who are taking MAO inhibitors should avoid ingesting foods that are high in tyramine, which can result in hypertensive crisis. Some foods to be avoided include cheese (especially aged cheese), yeast and yeast extract, chocolate, sherry, beer and red wine, smoked meats, ripe bananas, smoked fish, pickled herring, liver, soy sauce, ripe avocado, figs, and yogurt.

The nurse managing the care of a client diagnosed with schizophrenia should include which intervention into the client's plan of care after being prescribed an antipsychotic medication? Select all that apply. 1.Encourage the client to chew gum. 2.Assess the client for possible urinary retention. 3.Educate the client to the increased risk of developing hypoglycemia. 4.Monitor the client's menu selections to ensure adequate fiber consumption. 5.Provide the client with sunglasses when being taken outdoors for recreational walks.

ANS: 1,2,4,5 Rationale: Antipsychotic medication can produce side/adverse effects that include urinary retention, dry mouth, constipation, and photosensitivity. Diabetes mellitus (hyperglycemia) is a potential risk with the use of some antipsychotic medications.

The nurse instructs the client to be sure to take which action while taking newly prescribed lithium carbonate? 1.Limit salt intake. 2.Limit food intake. 3.Maintain a fluid intake of 2 to 3 L/day. 4.Stop the medication if gastrointestinal disturbances occur.

ANS: 3 Rationale: Lithium carbonate is prescribed for clients requiring mood stabilization. The client who begins taking lithium carbonate must maintain a fluid intake between 2 and 3 L/day. The client should also maintain normal salt intake. Both of these are necessary to avoid dehydration. Gastrointestinal disturbances generally disappear during continued therapy. It is not necessary to limit food intake.

A client experiencing delusions of being poisoned is admitted to the hospital. The client shows no evidence of dehydration and malnutrition at this time. The nurse creates a plan of care for the client and should include which client needs as the priority? 1.Self-esteem 2.Physiological 3.Safety and security 4.Love and belonging

ANS: 3 Rationale: The maintenance of safety is an important consideration when working with clients who have delusions. No data in the question indicate that options 1, 2, and 4 require immediate attention.

The nurse is performing an admission interview on a client being admitted to the mental health unit and discovers that the client experienced a severe emotional trauma 1 month ago and is now experiencing paralysis of the right arm. The nurse should plan for which priority intervention? 1.Referring the client to group therapy. 2.Encouraging the client to talk about his feelings. 3.Encouraging the client to move and use the arm. 4.Checking the client for organic causes of the paralysis.

ANS: 4 Rationale: The priority intervention is to check the client for any physiological cause of the paralysis. Although the client may be referred to group therapy, this is not the priority. Although a component of the plan of care is to encourage the client to discuss feelings, this also is not the priority. It is not appropriate to encourage the client to use the arm without ruling out a physiological cause of the paralysis.

A client has begun taking phenelzine. At the initiation of therapy, the client is taught which foods are acceptable to consume? Select all that apply. 1.Avocados 2.Figs and raisins 3.Bologna or salami 4.Carrots or radishes 5.Sweet potatoes and squash 6.Red wine, such as Chianti or sherry

ANS: 4,5 Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid foods that are high in tyramine because they could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, avocados, raisins, and figs. Vegetables are generally acceptable, with the exception of broad beans, including fava beans.

A client who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. What responses are appropriate for the nurse to use? (Select all that apply) A. call a staff member to escort the client to his room. B. ask the client to talk about what is causing him to be upset. C. ignore the client's inappropriate behavior. D. remind the client of the unit rules. E. tell the client to talk to his HCP about his privileges.

ANS: B,D Rationale: Therapeutic responses to disruptive behavior should start with the nurse's reflective interpretation of the client's distress followed with an open ended statement. "You seem upset, tell me about it." A discussion of unit rules also provides an opportunity to explain how to obtain privileges to walk the grounds. The other options are not appropriate ways to respond to this situation.

A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client? 1.Crush the tablets before taking them. 2.Mix the tablet uncrushed in apple sauce. 3.Purchase the liquid preparation with the next refill. 4.Call the health care provider for a change in medication.

ANS:1 Rationale: Buspirone may be administered without regard to meals, and the tablets may be crushed. Mixing the tablet uncrushed in apple sauce will not ensure ease in swallowing. This medication is not available in liquid form. It is premature to advise the client to call the health care provider (HCP) for a change in medication without first trying alternative interventions.

The nurse is caring for a client who is taking a maintenance dosage of lithium carbonate. What nursing action should be included in the client's plan of care? 1.Monitoring intake and output 2.Reviewing daily serum lithium levels 3.Performing a weekly electrocardiogram 4.Observing for remission of a depressive state

ANS:1 Rationale: This medication is very dependent on stable body fluid levels, and so monitoring daily intake and output is critical. Lithium is used to treat manic disorders, not depression. Side/adverse effects of lithium are nausea, tremors, polyuria, and polydipsia. Serum lithium concentration is assessed approximately every 2 to 4 days during initial therapy and at longer intervals thereafter. Toxic levels of lithium may induce electrocardiogram changes; however, performing weekly ECGs is unnecessary if therapeutic levels are maintained

A client is prescribed tranylcypromine. The nurse educating a client about tranylcypromine should instruct the client to avoid which activity? 1.Drinking any amount of wine 2.Consuming any fresh dairy products 3.Exposing the skin of the face to sunlight 4.Eating either fresh or frozen green leafy vegetables

ANS:1 Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. Food and fluids containing tyramine, such as aged cheese, smoked or pickled meats or poultry, fermented meat, beer, wine, and liqueurs, should not be used concurrently with MAOIs because they can cause sudden and severe hypertensive reactions. The remaining options are not contraindicated with the use of this medication.

The nurse is providing dietary instructions to a client who is prescribed tranylcypromine sulfate. The nurse emphasizes that it is important to avoid eating which food? 1.Salami 2.Scallops 3.Pineapple 4.Mashed potatoes

ANS:1 Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. A tyramine-restricted diet is required during therapy to avoid hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef liver, chicken liver, and dry sausage (salami, pepperoni, and bologna). In addition, figs, bananas, aged cheese, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and foods that are aged, pickled, fermented, or smoked need to be avoided. Many over-the-counter medications also include tyramine and must be avoided as well.

The nurse is caring for an emergency department client admitted with a suspected overdose of amitriptyline, a tricyclic antidepressant medication. What are the initial actions to take for this overdose? Select all that apply. 1.Check vital signs. 2.Order a psychiatric consult. 3.Contact a cardiologist STAT. 4.Obtain an electrocardiogram (ECG). 5.Draw blood for diagnostic laboratory studies. 6.Check and maintain a patent airway and administer oxygen.

ANS:1,4,5,6 Rationale: Actions to take for a tricyclic antidepressant overdose include obtaining an ECG, checking vital signs, drawing blood for diagnostic laboratory tests, and checking and maintaining a patent airway and administering oxygen. Initially it is not necessary to contact a cardiologist STAT or order a psychiatric consult. Other actions include preparing for gastric lavage with activated charcoal; preparing to administer physostigmine and antidysrhythmic medications; and documenting the event, actions taken, and the client's response.

A client who is receiving lithium carbonate has a serum level of 1.8 mEq/L. Which intervention will the nurse implement in response to this diagnostic result? 1.Plan rest periods into the client's daily routine. 2.Monitor the client for behaviors that suggests ataxia. 3.Document incidences that the client has begun to demonstrate mood stability. 4.Notify the client's health care provider that the medication dosage needs to be increased.

ANS:2 Rationale: A serum lithium level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentrations of 1.5 to 2.5 mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching, and slurred speech. The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A level below that indicates a need for an increase in dosage. Fatigue is a common side effect of this medication.

A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the health care provider will prescribe which medication to treat this condition? 1.Haloperidol 2.Benztropine 3.Chlorpromazine 4.Prochlorperazine

ANS:2 Rationale: Benztropine is an anticholinergic medication used to treat drug-induced extrapyramidal reactions (except tardive dyskinesia). The remaining options are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions.

The nurse gathers data from the client who was prescribed buspirone hydrochloride 1 month ago. The nurse interprets that the medication is effective when the client reports an absence of which event? 1.Delusions 2.Severe anxiety 3.Alcohol cravings 4.Paranoid thoughts

ANS:2 Rationale: Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression. It is not recommended for the treatment of thought disorders (delusions), drug or alcohol cravings, or schizophrenia (paranoid thoughts).

The nurse is conducting a health assessment on a client. The nurse asks, "What do you think caused your illness?" What type of question did the nurse ask? 1.Focused 2.Open-ended 3.Caring, beliefs, and practices 4.Biocultural ecology and health risks

ANS:2 Rationale: By asking "What do you think?" the nurse opens up the conversation for the client to expand on and explain rather than simply providing a yes or no answer. The other options are not descriptive of the type of question asked.

A client prescribed chlorpromazine hydrochloride calls the mental health clinic to report urine that is much darker than usual. The client currently has no other urinary symptoms. What instructions should the nurse provide the client based on this information? 1.To seek treatment for a possible urinary tract infection 2.That this is an expected side effect of the medication 3.To increase the daily intake of acid-ash foods and liquids 4.That this symptom indicates mild chlorpromazine hydrochloride toxicity

ANS:2 Rationale: Chlorpromazine hydrochloride is an antipsychotic medication. A side effect of this medication is that the color of urine may darken. The client should be aware that this effect is harmless. The other options are incorrect and not associated with this medication.

Which assessment has priority when conducting an admission assessment and history on a client diagnosed with an eating disorder? 1.Esteem focusing on positive self-esteem 2.Physiological focusing on cardiac function 3.Safety focusing on access to nutritious food 4.Self-actualization focusing on problem-solving skills

ANS:2 Rationale: Electrolyte imbalances are seen in clients with eating disorders. An imbalance of potassium can result in cardiac dysrhythmias. Although the other options are appropriate, these assessments do not have the priority of physiological needs.

A client is prescribed fluphenazine daily. The nurse teaches the client to take which measure to minimize a common side/adverse effect of this medication? 1.Monitor the temperature daily. 2.Use hard sour candy or sugarless gum. 3.Eat snacks at midmorning and at bedtime. 4.Have the blood pressure checked once a week.

ANS:2 Rationale: Fluphenazine is an antipsychotic. Dry mouth is a common side effect of this medication. Frequent mouth rinsing with water, sucking on hard candy, and chewing sugarless gum will alleviate this common side effect. Mild leukopenia may occur, but the temperature does not need to be taken daily. Weight gain is a common side effect, and frequent snacks would worsen the problem. Hypotension and hypertension are rare side effects of fluphenazine.

The client develops involuntary movements of the mouth with rhythmic tongue protrusion. Which medication should the nurse identify as the cause of this new development? 1.Diazepam, a benzodiazepine 2.Haloperidol, an antipsychotic 3.Benztropine, an anticholinergic 4.Diphenhydramine, an antihistamine

ANS:2 Rationale: Haloperidol is an antipsychotic that may be prescribed to alleviate psychotic features, such as paranoia and hallucinations. Haloperidol has a very high incidence of extrapyramidal symptoms (EPS) (repetitive, involuntary muscle movements, such as lip smacking or an undeniable urge to be moving constantly). The other options are medications that are associated with EPS, but rather than cause them, their role is to relieve the symptoms of EPS.

The nurse developing a teaching plan for a client being prescribed phenelzine sulfate should instruct the client to avoid which item? 1.Vasodilators 2.Aged cheeses 3.Digitalis preparations 4.Cherries and blueberries

ANS:2 Rationale: Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. A client taking an MAOI must avoid foods that contain tyramine such as aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. Other food items to avoid include chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. Clients taking MAOI medications also should avoid levodopa and meperidine. The items identified in the other options need not be avoided.

The nurse is admitting a client to the unit with a history of severe alcohol abuse. What are some of the signs of early alcohol withdrawal? Select all that apply. 1.Anger 2.Tremors 3.Anorexia 4.Irritability 5.Restlessness 6.Hypotension

ANS:2,3,4,5 Rationale: Early signs of alcohol withdrawal include tremors, anorexia (nausea and vomiting may occur), irritability, and restlessness. Anger is not a typical sign of early alcohol withdrawal, nor is hypotension. Other early signs include hypertension (not hypotension), hyperalertness, tachycardia, insomnia, jerky movements, easy startling, hallucinations (or vivid nightmares, illusions or delusions), and seizures. A feeling as though one is "shaking inside" may also occur.

The nurse is working on a mental health unit and administering many antipsychotic medications to clients. What are some indications for administering these medications? Select all that apply. 1.Anxiety 2.Schizophrenia 3.Bipolar disorders 4.Delusional disorders 5.Depressive psychoses 6.Medication-induced psychoses

ANS:2,3,4,5,6 Rationale: Antipsychotic medications are used to treat schizophrenia, bipolar disorder, delusional disorders, depressive psychoses, and medication-induced psychoses. These medications are not used to treat anxiety. Rather, antianxiety medications will be used to treat anxiety.

According to the DSM-5 diagnostic criteria for schizophrenia, which are characteristic negative symptoms of schizophrenia? Select all that apply. 1.Paranoia 2.Blunted affect 3.Poor judgment 4.Hallucinations 5.Social withdrawal 6.Disordered thinking

ANS:2,3,5 Rationale: Characteristic negative symptoms of schizophrenia include blunted affect, poor judgment, and social withdrawal. Other negative symptoms include emotional withdrawal, lack of motivation, poverty of speech, poor insight, and poor self-care. Besides paranoia, hallucinations, and disorganized thinking, other positive symptoms include delusions, disorganized speech, combativeness, and agitation.

The maternity nurse assesses clients for abuse at each prenatal visit and on admission to labor. Why are battering episodes sometimes initiated or increased in pregnancy? Select all that apply. 1.The woman and the man may argue over money. 2.The man may be angry at the unborn child or the woman. 3.The woman may make the man feel that he is not competent to be a father. 4.The beating may be the man's conscious or subconscious attempt to end the pregnancy. 5.The man may be jealous and resent the intrusion of the infant and the displacement of the woman's attention. 6.Biopsychosocial stresses and frustration of pregnancy can interfere with coping in the relationship and lead to violence.

ANS:2,4,5,6 Rationale: Some reasons why battering episodes are initiated or increased in pregnancy include the following: the man may be angry at the unborn child or the woman; the beating may be the man's conscious or subconscious attempt to end the pregnancy; the man may be jealous and resent the intrusion of the infant and the displacement of the woman's attention and biopsychosocial stresses and frustration of pregnancy can interfere with coping in the relationship and lead to violence. Arguing over money is not one of the reasons for battering. Stating that the woman may make the man feel that he is not competent to be a father is blaming the victim.

The nurse is managing the care of a client with acute schizophrenic relapse. How does the nurse advocate for the client regarding expected needs during the anticipated stabilization phase? 1.The nurse maintains a stable, predictable milieu. 2.The nurse fosters a mutually respectful, supportive nurse-client relationship. 3.The nurse includes the client in discussions regarding supervised group home living arrangements. 4.The nurse assesses the understanding of the condition processed by both the client and the family members.

ANS:3 Rationale: Advocating supports the client's right to be involved in treatment decision-making. One of the decisions made in preparation for the stabilization phase of a client recovering from a relapse of schizophrenic symptomology is appropriate housing arrangements. Maintaining a therapeutic milieu and nurse-client relationship are nursing responsibilities that are expected and strived for during all phases of client care. Assessing understanding of the condition would be done periodically throughout the client's period of care.

The primary health care provider prescribes aripiprazole for a client with a diagnosis of schizophrenia. Which nursing intervention would be therapeutic? 1.Administer the medication only after meals. 2.Inform the client to limit his alcohol intake to 1 drink each day. 3.Inform the client that the medication may cause sedation and should be taken at bedtime. 4.Instruct the client to increase his usual exercise pattern threefold to help with medication absorption.

ANS:3 Rationale: Aripiprazole is an antipsychotic agent that may be referred to as a dopamine system stabilizer (DSS). Because antipsychotics cause sedation, bedtime dosing helps promote sleep while decreasing daytime drowsiness. Aripiprazole may be administered with or without food and is well absorbed both in the presence or absence of food. It is not necessary for the client to increase his or her usual exercise pattern to assist in absorption of the medication. Alcohol is avoided, not limited.

A client diagnosed with schizophrenia has a new prescription for risperidone. The nurse should review which baseline laboratory result before administering the first dose of this medication? 1.Platelet count 2.Blood clotting tests 3.Liver function studies 4.Complete blood cell count

ANS:3 Rationale: Baseline assessment of renal and liver function tests should be done before initiating risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in older or debilitated clients. These clients are started on the medication at a reduced dosage level.

The nurse is caring for a client who has been prescribed disulfiram. Which statement by the client indicates to the nurse the need for further teaching about this medication? 1."I'll have to check my aftershave lotion." 2."I must be careful taking cold medicines." 3."As long as I don't drink alcohol, I'll be fine." 4."I'll have to be careful with the ingredients I use for cooking."

ANS:3 Rationale: Clients who are taking disulfiram must be taught that substances containing alcohol can trigger an adverse reaction. Sources of hidden alcohol include foods (soups, sauces, vinegars), medicine (cold medicine), mouthwashes, and skin preparations (alcohol rubs, aftershave lotions).

A client is prescribed a monoamine oxidase inhibitor. What is the primary reason the nurse needs to assess this client closely? 1.Risk of liver damage may be increased. 2.Bradycardia and hypotension may indicate toxicity. 3.Headache, hypertension, and nausea and vomiting may indicate toxicity. 4.Hypotensive crisis may be precipitated by foods rich in tyramine and tryptophan.

ANS:3 Rationale: Headache, hypertension, tachycardia, nausea, and vomiting are precursors to hypertensive crisis brought about by the ingestion of foods rich in tyramine and tryptophan while the client is taking monoamine oxidase inhibitors (MAOIs). These medications act by decreasing the amount of monoamine oxidase in the liver, which is necessary for the breakdown and use of tyramine and tryptophan. Hypertensive crisis may lead to circulatory collapse, intracranial hemorrhage, and death.

At what time of day does the nurse recommend that a child prescribed methylphenidate be given the last dose of the day of the medication? 1.At bedtime 2.With a bedtime snack 3.Just before the noontime meal 4.In the morning, 2 hours before breakfast

ANS:3 Rationale: Methylphenidate is used to treat attention deficit hyperactivity disorder and has stimulant effects. Children with should take the morning dose after breakfast and the last daily dose should be taken at least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia. Usually the health care provider recommends that the last dose be given just before the noontime meal. The other options are incorrect.

A client receiving long-term therapy with lithium carbonate has a serum lithium level of 1.0 mEq/L. Which nursing intervention should the nurse be prepared to implement based on this result? 1.Monitor the client for signs of coarse hand tremors. 2.Assess the client for possible short-term memory loss. 3.Provide positive support for the client's compliance with the therapy. 4.Educate the client regarding risk for injury associated with drowsiness.

ANS:3 Rationale: The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L, and the client's medication compliance should be acknowledged. Serum lithium concentrations of 1.5 to 2.0 mEq/L may produce a variety of toxicity symptoms, including vomiting, diarrhea, drowsiness, incoordination, coarse hand tremors, muscle tremors, and mental confusion.

The nurse should monitor the client prescribed thioridazine hydrochloride carefully for which adverse effect? 1.Weight gain 2.Photosensitivity 3.Cardiac dysrhythmias 4.Extrapyramidal movements

ANS:3 Rationale: Thioridazine hydrochloride is an antipsychotic medication that may be prescribed for the schizophrenic client when other medications have failed to manage the symptoms. Cardiac dysrhythmias are an adverse effect of thioridazine. Weight gain and extrapyramidal movements are not associated with this medication. Photosensitivity is a rare side effect.

The nurse is discussing the past week's activities with a client receiving amitriptyline hydrochloride. The nurse determines that the medication is most effective for this client if the client reports which information? 1.A decrease in intrusive thoughts 2.Sleeping 14 to 16 hours each day 3.Ability to get to work on time each day 4.An improvement in short-term memory

ANS:3 Rationale: This medication is prescribed for the management of depression. Depressed individuals may demonstrate a lack of energy that results in sleeping for extended periods and being unable to fulfill employment obligations. The therapeutic effect of this medication is intended to help resolve these symptoms. Sleeping 14 to 16 hours is still a demonstration of depression-associated fatigue. The medication is not intended to manage intrusive thoughts (delusions) or to improve memory.

What is the most serious risk associated with the use of benzodiazepine? 1.Headache 2.Vomiting 3.Skin rashes 4.Dependence

ANS:4 Rationale: A benzodiazepine carries with it a high risk for abuse and physical and psychological dependence. For this reason, limited amounts of these medications are given to a client at one time. The other symptoms may be side effects of some benzodiazepines but are not as serious as the risk of dependence.

When providing client education on the medication alprazolam, why is it essential to include the importance of avoiding abrupt discontinuation of the medication? 1.Irreversible kidney damage is likely to occur. 2.The original symptoms will be greatly intensified. 3.The medication will be much less effective if it must be restarted. 4.Rebound central nervous system excitation could cause seizure activity.

ANS:4 Rationale: Alprazolam is a benzodiazepine used to manage anxiety disorders. The abrupt withdrawal of alprazolam could result in seizure activity from central nervous system excitation. All clients receiving this medication should be warned of this danger. The other options are incorrect.

A hospitalized client is being treated for depression with amitriptyline hydrochloride. The nurse should take which most important nursing intervention during the initial phases of treatment? 1.Obtain frequent medication blood levels. 2.Provide the client with a tyramine-free diet. 3.Assess the client for anticholinergic effects. 4.Obtain postural blood pressures before administering each dose.

ANS:4 Rationale: Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. The client may experience some side effects such as sedation, dry mouth, constipation, and blurred vision (anticholinergic). However, these are transient and will diminish as time goes on. A more common adverse effect is orthostatic changes that can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it may result in dizziness and falling. The client must be instructed to move slowly from the lying position to the sitting or standing position to avoid injury if these changes are experienced. A tyramine-free diet is initiated for a client on a monoamine oxidase inhibitor. Blood levels are required for the client taking lithium, which is used to treat bipolar disorder.

A client has been prescribed clozapine. The nurse reviews the result of which laboratory study to detect a serious adverse effect associated with this medication? 1.Platelet count 2.Liver function 3.Blood glucose level 4.White blood cell count

ANS:4 Rationale: Clozapine is an antipsychotic medication. The client taking clozapine may experience agranulocytosis as an adverse effect, which is monitored by obtaining weekly white blood cell counts. Treatment is withheld if the level drops below 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other options are incorrect.

The nurse provides medication education to the client who is prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which diet choice by the client indicates a correct understanding of the instructions? 1.Chianti wine 2.Sausage and pepperoni pizza 3.Romaine salad with avocado and figs 4.Spaghetti with tomato basil marinara sauce

ANS:4 Rationale: MAOIs can interact with foods that require bacteria or molds for preparation and foods containing tyramine, such as wine, avocados, figs, sausages, and pepperoni. Of the choices provided, the only safe food is spaghetti with tomato basil marinara sauce.

Which assessment findings suggest to the nurse that the client is experiencing tardive dyskinesia? 1.Severe headache, flushing, tremors, and ataxia 2.Abnormal breathing through the nostrils, accompanied by a thrill 3.Severe hypertension, migraine headache, and "marbles in the mouth" syndrome 4.Movements of the mouth, tongue, and face that are both abnormal and involuntary

ANS:4 Rationale: Tardive dyskinesia is an adverse effect associated with long-term use of antipsychotic medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("fly-catcher tongue"), and face. In its more severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. None of the remaining options are manifestations associated with this adverse effect.

Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen? A) Signs and symptoms of extrapyramidal effects (EPS). B) Information about substance abuse and schizophrenia. C) The effects of alcohol and drug interaction. D) The availability of support groups for those with dual diagnoses.

Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. (A, B, and D) provide valuable information and should be included in the client/family teaching, but they do not have the priority of (C). Correct Answer(s): C

A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage? A) He ingested the drug 3 hours prior to admission to the emergency center. B) The family reports that he took an entire bottle of acetaminophen (Tylenol). C) He is unresponsive to instructions and is unable to cooperate with emetic therapy. D) Those with repeated suicide attempts desire punishment to relieve their guilt.

Because the client is unable to follow instructions, emetic therapy would be very difficult to implement and gastric lavage would be necessary (C). (A and B) should be considered in determining the course of treatment, but they are not the basis for determining if gastric lavage will be implemented. Medical treatments should never be used as "punitive" measures (D). Correct Answer(s): C

A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.) A) Compulsions relieve anxiety. B) Anxiety is the key reason for OCD. C) Obsessions cause compulsions. D) Obsessive thoughts are linked to levels of neurochemicals. E) Antidepressant medications increase serotonin levels.

Correct choices are (A, B, D, and E). To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology. Compulsions are behaviors that help relieve anxiety (A), which is a vague feeling related to unknown fears, that motivate behavior (B) to help the client cope and feel secure. All obsessions (C) do not result in compulsive behavior. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals (D), particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI). Correct Answer(s): A, B, D, E

On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder? A) Neurotic. B) Personality. C) Anxiety. D) Psychotic.

Delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in touch with reality (D). (A, B, and C) are mental health disorders which are not associated with a break in reality, nor with hallucinations (false sensations such as hearing, or seeing) or delusions (false beliefs). Correct Answer(s): D

The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention bests helps this client deal with his depression? A) Ensure that the client's day is filled with group activities. B) Assist the client in exploring feelings of shame, anger, and guilt. C) Allow the client to initiate and determine activities of daily living. D) Encourage the client to explore the rationale for his depression.

Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings is an important nursing intervention for the depressed client (B). If the client's day is filled with group activities (A) he might not have the opportunity to explore these feelings. (C) is a good intervention for the chronically depressed client who exhibits vegetative signs of depression. (D) is essentially asking the client "why" he is depressed--avoid "why's" disguised as "rationale." Correct Answer(s): B

A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? A) Reassure the client by telling him that his fear of the admission procedure is to be expected. B) Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. C) Assess the content of the hallucinations by asking the client what he is hearing. D) Ignore the behavior and make no response at all to his delusional statements.

Further assessment is indicated (C). The nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill the nurse! (A) is telling the client how he feels (fearful). The nurse should leave communications open and seek more information. (B) is arguing with the client's delusion, and the nurse should never argue with a client's hallucinations or delusions, also (B) is possibly offering false reassurance. (D) is avoiding the situation and the client's needs. Correct Answer(s): C

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? A) Administer a prescribed PRN antianxiety medication. B) Assist the client to identify stimuli that precipitates the ritualistic activity. C) Allow time for the ritualistic behavior, then redirect the client to other activities. D) Teach the client relaxation and thought stopping techniques.

Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as treatment progresses. Correct Answer(s): C

A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A) The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities. B) The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the authorities. C) The nurse should report any case of suspected child abuse to the nurse in charge. D) The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions can be tracked.

It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process (C). Correct Answer(s): C

A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression? A) Grandiose ideation. B) Self-destructive thoughts. C) Suspiciousness of others. D) A negative view of self and the future.

Negative self-image and feelings of hopelessness about the future (D) are specific indicators for depression. (A and/or C) occurs with paranoia or paranoid ideation. (B) may be seen in depressed clients, but are not always present, so (D) is a better answer than (B). Correct Answer(s): D

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment? A) Altered thought processes. B) Moderate levels of anxiety. C) Inadequate social support. D) Altered health maintenance.

The nurse should initiate a referral based on anxiety levels (B) and feelings of nervousness that interfere with sleep, appetite, and the inability to solve problems. The client does not report symptoms of (A) or evidence of (C). There is not enough information to initiate a referral based on (D). Correct Answer(s): B

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? A) When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. B) While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms. D) I will continue to take my benztropine mesylate (Cogentin) every day.

Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its tropical island climate) increases the client's chance of experiencing this side effect. He should be instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). (C) lists signs of agranulocytosis, which is also a side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with Prolixin. Correct Answer(s): A

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A) Client will not demonstrate cross-addiction. B) Co-dependent behaviors will be decreased. C) Excessive CNS stimulation will be reduced. D) Client's level of consciousness will increase.

Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described, but do not have the priority of (C). Correct Answer(s): C

The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? A) Ineffective denial related to situational anxiety. B) Ineffective coping related to inadequate support. C) Social isolation related to difficult interactions. D) Self-care deficit related to cognitive impairment.

The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements. Correct Answer(s): A

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time? A) Isolation. B) Stagnation. C) Despair. D) Role confusion.

The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family (B). (A) occurs in young adulthood (age 18 to 25), (C) occurs in maturity (age 45 to death), and (D) occurs in adolescence (age 12 to 20). These are all stages that occur if individuals are not successfully coping with their psychosocial developmental stage. Correct Answer(s): B

The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? A) Crickets are a good source of protein. B) I have not heard any voices for a week. C) Only my belief in God can help me. D) Sometimes I have a hard time sitting still.

The most frequent cause of increased symptoms in psychotic clients is non-compliance with the medication regimen. If clients believe that "God alone" is going to heal them (C), then they may discontinue their medication, so (C) would pose the greatest threat to this client's prognosis. (A) would require further teaching, but is not as significant a statement as (C). (B) indicates an improvement in the client's condition. (D) may be a sign of anxiety that could improve with treatment, but does not have the priority of (C). Correct Answer(s): C

A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care? A) Reassure the client that no one will harm her while she is in the hospital. B) Ask the healthcare provider to give the client the medication. C) Explain that the diabetic medication is important to take. D) Reassess client's mental status for thought processes and content.

The most important intervention is to reassess the client's mental status (D) and to take further action based on the findings of this assessment. Attempting to reassure the client (A) is in effect arguing with the client's delusions and could escalate an already anxious situation. Collaborating about diabetic care (B and C) is not likely to help change the client's false beliefs. Correct Answer(s): D

The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? A) Excessive work activity. B) Decreased need for sleep. C) Medication management. D) Inflated self-esteem.

The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems do not have the priority of medication management. Correct Answer(s): C

An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? A) Plan an outing within the first week of admission. B) Distract her whenever she expresses her discomfort about being with others. C) Confront her fears and discuss the possible causes of these fears. D) Accompany her outside for an increasing amount of time each day.

The process of gradual desensitization by controlled exposure to the situation which is feared (D), is the treatment of choice in phobic reactions. (A and C) are far too aggressive for the initial treatment period and could even be considered hostile. (B) promotes denial of the problem, and gives the client the message that discussion of the phobia is not permitted. Correct Answer(s): D