MH

A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment?

Dangerous

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

Darting eyes, tilted head, mumbling to self

A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms?

She should experience a reduction in hallucinations.

What is the nurse's priority-focused assessment for side effects in a child taking methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)?

Sleep disturbances and weight loss

Soon after the parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority?

Social Isolation

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should:

maintain a normal social interaction distance from the patient.

A health teaching plan for a patient taking lithium should include instructions to:

maintain normal salt and fluids in the diet.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with:

meals.

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will:

perform self-care activities with coaching by the end of day 3.

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by:

putting a blanket around the patient and walking with the patient to a quiet room.

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, is inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to:

reduce loneliness and increase self-esteem.

The exact cause of bipolar disorder has not been determined; however, for most patients:

several factors, including genetics, are implicated.

When a 5-year-old is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will:

sit on the edge of the activity until able to regain self-control.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is:

within therapeutic limits.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide?

"A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder.

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child:

continuously rocks in place for 30 minutes.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior?

improved abilities to participate in cooperative play with other children

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse:

invites the patient to sit together and look at new fashion magazines.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification?

lamotrigine (La-mictal)

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?

Poor judgment and hyperactivity

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?

Poor personal hygiene

Which finding constitutes a negative symptom associated with schizophrenia?

Poverty of thought

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?

"Do not hit anyone. If you are unable to control yourself, we will help you."

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response.

"Feeling that people want to destroy you must be very frightening."

A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, "What should we do?" Select the nurse's best response.

"Give your child a kiss before you leave the preschool program."

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response.

"I am having difficulty understanding what you are saying."

A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply.

"I'll stay with you. Focus on what we are talking about, not the voices. "

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority?

"The importance of taking your medication correctly" "Ways to quit smoking"

A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking?

"The table of contents tells what a book is about."

Which hallucination necessitates the nurse to implement safety measures? The patient says,

"The voices say everyone is trying to kill me."

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate?

"Tics often change frequency or severity. That doesn't mean they aren't real."

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question.

"What is the voice telling you to do?"

Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?

"You say you hear voices, what are they telling you?"

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response.

"You're laughing. Tell me what's happening."

At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? Select all that apply.

- Educate all members of the family about risks associated with cyberbullying. - Talk with the parents about parental controls on the children's communication devices. - Encourage the family to schedule daily time together without communication devices.

A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate?Select all that apply.

-Risk for other-directed violence -Disturbed thought processes

Which child demonstrates behaviors indicative of a neurodevelopmental disorder?

A 3-year-old who is mute, passive toward adults, and twirls while walking

A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as:

A neologism

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?

Pseudoparkinsonism

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend?

Psychoeducational

Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness?

The child has been raised by a parent with chronic major depression.

A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority?

Acceptance and trust convey feelings of security to the child.

A nurse prepares to lead a discussion at a community health center regarding children's health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? Select all that apply.

Bullying, Autism spectrum, intellectual development disoder

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?

Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?

Allowing the patient supervised access to food vending machines

Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia?

Always afraid another student will steal her belongings.

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?

An acute dystonic reaction

Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas's nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with:

Anxiety and depression.

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?

Aripiprazole (Abilify)

A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident?

Associative looseness

A child diagnosed with attention deficit hyperactivity disorder will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?

Central nervous system stimulants

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select?

Distraction: "Let's go to the dining room for a snack."

A child reports to the school nurse being verbally bullied by an aggressive classmate. What is the nurse's best first action?

Encourage the victimized child to share feelings about the experience.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood?

Euphoric

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially?

Hold a staff meeting to discuss consistency and limit-setting approaches.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care?

Hyperactivity; not eating and sleeping

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders?

Impaired social interaction related to difficulty relating to others.

Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others' conversations. How should the nurse document these behaviors?

Impulsivity

Which factor presents the highest risk for a child to develop a psychiatric disorder?

Living with an alcoholic parent.

A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident?

Magical thinking

A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which medication will the information focus on?

Methyphenidate (Ritalin)

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action.

Neuroleptic malignant syndrome; notify health care provider stat.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate?

Neutral walls with pale, simple accessories

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?

Olanzapine (Zyprexa)

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident?

Paranoia

Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia?

Paranoia

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

Physiological

When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses:

Play and talk about a play activity

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of:

Relapse

The ability to adapt and cope helps people to face tragedies, loss, trauma, and severe stress

Resilience

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority?

Risk for injury

Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia?

Screening a group of males between the ages of 15 and 25 for early symptoms.

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient?

Sedation and muscle stiffness

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention?

Set limits on patient behavior as necessary.

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care?

Social skills group

When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action?

Take the aggressive child to another room.

A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

Tardive dyskinesia

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action.

Tell the client, "You are in a safe place where you will be helped."

The style of behavior a child habitually uses to cope with the demands and expectations of the environment

Temperament

When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that:

They are not actually ill.

Gilbert, age 19, is described by his parents as a "moody child" with an onset of odd behavior about at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:

To have a less positive outcome

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan.

Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return.

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

Waxy flexibility

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication?

Weight management strategies

What assessment findings mark the prodromal stage of schizophrenia?

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding?

Word salad

To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition?Select all that apply.

a. Alcohol use disorder b. Major depressive disorder d. Polydipsia e. Metabolic syndrome

Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.

a. Hold his medication and contact his prescriber. b. Wipe him with a washcloth wet with cold water or alcohol.

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as:

an idea of reference.

The child prescribed antipsychotic medication to manage violent behavior is one most likely diagnosed with:

attention deficit hyperactivity disorder.

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for:

attention deficit hyperactivity disorder.

Withdrawn patients diagnosed with schizophrenia:

avoid relationships because they become anxious with emotional closeness.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will:

bring hyperactivity under rapid control.

A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will: (select all that apply)

c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?

carbamazepine (Tegretol)

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child:

holds the parent's hand while walking.

The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will:

demonstrate improved social skills.

A parent diagnosed with schizophrenia and a 13-year-old child living in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child:

displays resiliency

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will:

drink six servings of a high-calorie, high-protein drink each day.

A child diagnosed with attention deficit hyperactivity disorder had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? The child:

engages in cooperative play with other children.