"Napa Know how" Mental Health Exam 1

Which statement if made by the alcoholic client to the nurse, indicates the client has an accurate understanding of the problem? 1. when i can learn to stop after one drink i will have my problems beat 2. when my family and work problems go away i won't need alcohol anymore 3. i can't seem to cope with my problems without drinking 4. in my business most people whir hard and drink too much

3. i can't seem to cope with my problems without drinking the client acknowledges that alcohol is used to cope with problems the client is beginning to break through denial

A client diagnosed with schizophrenia is referred for family therapy at a mental health clinic. in the first session the mom monopolizes the discussion. which of the following actions should the nurse take first? 1. politely ask the mother to be quiet to allow other family members to talk 2. allow the mother to ventilate since she has a need to do so 3. discuss the mothers monopolizing behavior with her privately after the session 4. ask the res of the family how they feel about the mother's talking

4. ask the rest of the family how they feel about the mother's talking because it is a group session the nurse wants feedback from the family about the effects of the mother's behavior has on them

3. 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 c. Stomach cancer d. Polydipsia e. Metabolic syndrome

A,B,D,E

The client diagnosed with schizophrenia is placed on haloperidol 5 mg bid. the nurse should observe the client for what symptoms 1. constipation/dry mouth 2. vomitting / diarrhea 3. diuresis and sodium loss 4. hypertension and insomnia

1. constipation and dry mouth high potency, high incidence of EPS effects

4. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially? a. Reinforce that the level is considered therapeutic. b. Instruct the patient to hold the next dose of medication and contact the prescriber. c. Have the patient go to the hospital emergency room immediately. d. Alert the patient to the possibility of seizures and appropriate precautions.

B

A patient diagnosed with schizophrenia was experiencing paranoid thinking. Which statement by this patient most clearly indicates the antipsychotic medication was effective? "I think the staff wants to help me." "I finished my project in arts and crafts group." "A nurse on the night shift gave me too much medicine." "I don't need to take medicine anymore. I do not have any problems."

"I think the staff wants to help me." Recognizing that the staff desires to be helpful suggests the paranoia is gone or has subsided. Finishing an art project, thinking the nurse is giving too much medicine, and believing that one no longer has a problem show a statement of accomplishment, paranoia, and anosognosia. pp. 203-205, Case Study and Nursing Care Plan

The nurse is teaching a patient and the patient's family about first- and second-generation antipsychotics for schizophrenia. What will the nurse include in the teaching? "Most people who take first-generation antipsychotics report fewer side effects." "Second-generation antipsychotics are mostly used for treating negative symptoms of schizophrenia." "First-generation antipsychotics are used more frequently than second-generation antipsychotics." "Second-generation antipsychotics are usually better than first-generation antipsychotics because they have fewer side effects."

"Second-generation antipsychotics are usually better than first-generation antipsychotics because they have fewer side effects." Both first- and second-generation antipsychotics are used to treat schizophrenia. Second-generation antipsychotics are used more frequently than and are starting to replace first-generation antipsychotics, because they are more effective with fewer side effects. Second-generation antipsychotics are used to treat positive symptoms of schizophrenia, not negative symptoms. First-generation antipsychotics are used less frequently than second-generation drugs, not more frequently. First-generation antipsychotics cause more negative side effects, not fewer side effects. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. p. 201

A nurse manager plans to follow up with a nurse after hearing which comment while talking to a patient who is reporting someone is trying to poison him or her? "Let's discuss the stressors you have in your life right now." "Tell me more about how someone keeps trying to poison your food." "Have other members of your family ever experienced this kind of thing?" "How has this affected your ability to keep a job or care for yourself?"

"Tell me more about how someone keeps trying to poison your food." It is nontherapeutic to reinforce the delusion by encouraging the individual to focus on the details, as suggested by asking the patient how his or her food is being poisoned. The statements "Have other members of your family ever experienced this kind of thing?", "How has this affected your ability to keep a job or care for yourself?", and "Let's discuss the stressors you have in your life right now" do not reinforce the delusion. Rather, they help gain knowledge about the history of the disorder in the family, the extent of the dysfunction the fear is causing, and the triggers that may have resulted in this behavior. p. 209, Box 12.4

Which of the following statements represent a nontherapeutic communication technique? Select all that apply. "Why didn't you attend group this morning?" "From what you have said, you have great difficulty sleeping at night." "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" "If I were you, I would quit the stressful job and find something else." "I'm really proud of you for the way you stood up to your brother when he visited today." "You mentioned that you have never had friends. Tell me more about that." "It sounds like you have been having a very hard time at home lately."

"Why didn't you attend group this morning?" "What did your boyfriend do that made you leave? Are you angry at him? Did he abuse you in some way?" "If I were you, I would quit the stressful job and find something else." "I'm really proud of you for the way you stood up to your brother when he visited today." All these options reflect the nontherapeutic techniques of (in order) asking "why" questions; using excessive questioning; giving advice; and giving approval. The other options describe therapeutic techniques of restating, exploring, and reflecting.DIF: Cognitive Level: Apply (Application)REF: pages 18, 19TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

With which client should the nurse make the assessment that not using touch would probably be in the client's best interests? A recent immigrant from Russia A deeply depressed client A Chinese American client A tearful client reporting pain

A Chinese American client Chinese Americans may not like to be touched by strangers since it is a cultural characteristic.REF: 148

A patient diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as Blocking A delusion A neologism Clang association

A neologism A neologism is a newly coined word that has meaning only for the patient. Clang association is choosing a word with similar sound like "click, clack, clutch." Blocking is related to thoughts and a stop or reduction in thoughts often related to interruptions caused by hallucinations. Delusions are false beliefs. p. 198

6. Substance abuse is often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that: a. Anxiety may be present. b. Alcohol ingestion is a form of self-medication. c. The patient is lacking a sufficient number of neurotransmitters. d. The patient is using alcohol because she is depressed.

B

9. Tatiana has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizziness

B

8. A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, "You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing": a. A higher dosage b. Once a week dosing c. A lower dosage d. A different drug

C

Which strategy will the nurse implement when caring for a patient who is experiencing auditory hallucinations? Call the patient by name. Remove the patient to a seclusion room. Assess for suicidal or homicidal commands. Work to maintain eye contact with the patient. Speak loud enough to attract the patient's attention.

Call the patient by name. Assess for suicidal or homicidal commands. Work to maintain eye contact with the patient. Speak loud enough to attract the patient's attention. When a patient is hallucinating, the nurse focuses on understanding the patient's experiences and responses. Suicidal or homicidal themes or commands necessitate appropriate safety measures. Call the patient by name, speak simply and loudly enough to be understood amid the hallucinations, present in a nonthreatening and supportive manner, maintain eye contact, and redirect the patient's focus to the conversation as needed. Removing the patient to seclusion is not always necessary and is implemented only when there are reasons to believe the patient poses harm to him- or herself or to others. p. 209, Box 12.3

During a therapeutic encounter, the nurse makes an effort to ensure the use of two congruent levels of communication. What is the rationale for this? The mental image of a word may not be the same for both nurse and client. One statement may simultaneously convey conflicting messages. Many of the client's remarks are no more than social phrases. Content of messages may be contradicted by process.

Content of messages may be contradicted by process. Verbal messages may be contradicted by the nonverbal message that is conveyed. The nonverbal message is usually more consistent with the client's feelings than the verbal message. None of the remaining options are so directly associated with assuring congruency.REF: 140-141

10. Luc's family comes home one evening to find him extremely agitated and they suspect in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting? a. Hypodermic needles b. Fast food wrappers c. Empty soda cans d. Energy drink containers

D

5. Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? a. Depersonalization b. Pressured speech c. Negative symptoms d. Paranoia

D

3. The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient? Select all that apply. a. Increased attentiveness b. Getting up at night to urinate c. Improved vision d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult

D,E

A patient with schizophrenia who is experiencing symptoms of disorganized thinking would have the greatest difficulty when the nurse Uses concrete language Gives multistep directions Interacts with a neutral attitude Provides nutritional supplements

Gives multistep directions The thought processes of the patient with disorganized schizophrenia are severely disordered, and severe perceptual problems are present, making it extremely difficult for the patient to understand what others are saying. All communication should be simple and concrete and may need to be repeated several times. p. 205, Table 12.3

The nurse documents that a patient is demonstrating a negative symptom of schizophrenia when observing the patient doing what? Refusing to eat anything that is not tasted by the staff first Having difficulty focusing on any task for more than a few minutes Communicating using a pattern of speech identified as "word salad" Reporting hearing voices telling the patient that the world will end soon

Having difficulty focusing on any task for more than a few minutes Attention impairment is considered a negative symptom because it represents a diminution or loss of normal brain function. Paranoia, hallucinations, and distorted speech are considered positive symptoms because they are an exaggeration or distortion of normal brain function. p. 201, Table 12.2

A nurse works with a patient in the acute phase of schizophrenia. Which assessment findings increase the risk of aggression and violence? Paranoia Flat affect Poor hygiene Delusional thinking Command hallucinations

Paranoia Delusional thinking Command hallucinations A small percentage of patients with schizophrenia, especially during the acute phase, may exhibit a risk for physical violence, typically in response to hallucinations (especially command hallucinations), delusions, paranoia, and impaired judgment or impulse control. Poor hygiene and a flat affect are negative symptoms that usually are not associated with aggression or violence. p. 203

During a therapeutic encounter the nurse remarks to a client, "I noticed anger in your voice when you spoke of your father. Tell me about that." What communication techniques is the nurse using? Giving information and encouraging evaluation Presenting reality and encouraging planning Clarifying and suggesting collaboration Reflecting and exploring

Reflecting and exploring Reflecting conveys the nurse's observations of the client when a sensitive issue is being discussed. Exploring seeks to examine a certain idea more fully.REF: 142

Which phase of the nurse-client relationship may cause client anxieties to reappear and past losses to be reviewed? Preorientation phase Orientation phase Working phase Termination phase

Termination phase Termination, a stage in which the client must face the loss or ending of the therapeutic relationship, often reawakens the pain of earlier losses. This is not generally associated with the other phases.REF: 132-133

What is the primary difference between a social and a therapeutic relationship? Type of information exchanged Amount of satisfaction felt Type of responsibility involved Amount of emotion invested

Type of responsibility involved In a therapeutic relationship the nurse assumes responsibility for focusing the relationship on the client's needs, facilitating communication, assisting the client with problem-solving, and helping the client identify and test alternative coping strategies.REF: 127-128

A patient diagnosed with schizophrenia says, "Cheese dog run fast." How should the nurse document this comment? Neologism Word salad Circumstantiality Magical thinking

Word salad A word salad is a jumble of words that is meaningless to the listener and results from an extreme level of disorganization. A neologism is an invented word. Circumstantiality refers to verbal expression with excessive detail. Magical thinking means believing that one's thoughts or actions can affect others. p. 198

The nurse interacts with the client diagnosed with depression. the nurse expects the client to express which thought? 1. I'm embarrassed that everyone has to take care of me 2. once my depression is over, ill be able to get on with life 3. i like being taken care f from time to time 4. I'm glad that i came for help in time

1. I'm embarrassed that everyone has to take care of me clients diagnosed with depression usually have feelings of guilt and unworthiness and have difficulty accepting help from others because of these feelings, will be embarrassed by their feelings of hopelessness

Which nursing approach is BEST when caring for a client diagnosed with a conversion reaction paralysis? 1. give special attention to paralyzed limb 2. point out to the client that paralysis reflects anxiety 3. minimize the sick role and secondary gains 4. attempt to have the client move periodically

3. Minimize the sick role and secondary gains Emphasis is to minimize the sick role and support clients strengths

A patient on a psychiatric unit complains to the nurse that his stomach is missing. Which response is most appropriate? 1. that's not possible you wouldn't be able to eat anything 2. i am here to help you with this problem 3. it sounds as if you feel very empty and alone 4. this is a common response to depression

3. it sounds as if you feel very empty and alone depressed patients often have delusions that a body organ is missing or diseased, delusions reflect feelings of emptiness and loneliness

Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

What is the most helpful nursing response to a client who reports thinking of dropping out of college because it is too stressful? "Don't let them beat you! Fight back!" "School is stressful. What do you find most stressful?" "I know just what you are going through. The stress is terrible." "You have only two more semesters. You will be glad if you stick it out."

"School is stressful. What do you find most stressful?" This response acknowledges the speaker's perception of school as difficult and asks for further information. This response suggests the nurse is listening actively and is concerned.REF: 142

The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for which characteristic of a dysfunctional nurse-patient relationship? Boundary blurring Value dissonance Covert anger Empathy

Boundary blurring Boundary blurring is often signaled by the nurse being either too helpful or not helpful enough. The behavior is not associated with any of the other options.REF: 127

A patient with schizophrenia was changed to clozapine 3 weeks ago. The patient calls the clinic nurse complaining of sore throat, fever, and malaise. Which laboratory test would be most helpful in determining the cause of these findings? Urinalysis Liver panel Serum lithium level Complete blood cell count

Complete blood cell count Agranulocytosis is the reduction of white blood cells (WBCs) and is a possible adverse effect of antipsychotic drugs, particularly clozapine. Chief complaints are flulike symptoms. A complete blood cell count would show the reduction in WBCs. Serum lithium level, liver panel, and urinalysis are not necessary. p. 217

A recent immigrant to the United States from which country would find direct eye contact a positive therapeutic technique? Korea Mexico Japan Germany

Germany Eye contact conveys interest to most northern European individuals. Eye contact would be considered intrusive to the others.REF: Page 147-148

A patient has reached the stable plateau phase of schizophrenia. An appropriate clinical focus for planning would be Acute symptom stabilization Safety and crisis intervention Stress and vulnerability assessment Social, vocational, and self-care skills

Social, vocational, and self-care skills During the stable plateau phase of schizophrenia, planning is geared toward the patient and family education and skills training that will help maintain the optimal functioning of schizophrenic individuals in the community. p. 196

Which assessment findings in a 19-year-old patient support the existence of prepsychotic-phase symptomology associated with schizophrenia? Depression Social awkwardness Narcissist tendencies Poor academic performance Demonstration of phobic fears

Depression Social awkwardness Poor academic performance Demonstration of phobic fears The onset of prepsychotic (prodromal) symptoms may appear a month to more than a year before the first psychotic break or full-blown manifestation of the illness. Often, before the illness, a person with schizophrenia is socially awkward, lonely, and perhaps depressed. In this prodromal phase, anxiety, phobias, obsessions, dissociation, and compulsions may be noted. Concentration, memory, and completion of school- or job-related work deteriorate. Narcissistic (self-absorbed, self-centered) tendencies are not classic prodromal characteristics. p. 196

A patient diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. A therapeutic response for the nurse would be "The voices are wrong about the hospital food. It is not contaminated." "You are safe here in the hospital; nothing bad will happen to you." "I understand that the voices are very real to you, but I do not hear them." "Other people are eating the food, and nothing is happening to them."

"I understand that the voices are very real to you, but I do not hear them." This reply acknowledges the patient's reality but offers the nurse's perception that he or she is not experiencing the same thing. p. 209, Box 12.4

A patient with schizophrenia reports to the nurse, "At night my business rival came to the hospital to kill me for my property." What is the most appropriate response of the nurse while handling such a patient? "Next time when you see him, call me." "Oh, really! Let's file a police complaint." "No one can come to the hospital in the night." "Because of your illness you are having hallucinations. No one can hurt you."

"Because of your illness you are having hallucinations. No one can hurt you." A patient with schizophrenia often has hallucinations. The nurse should try to persuade the patient to focus on reality by convincing him that these visions are part of the illness. This assurance makes the patient confident and does not support the illness. A nurse also should not neglect the patient's hallucinations because this can make the patient feel rejected and be at risk for withdrawing. It is advisable that the nurse does not encourage the patient's hallucination by saying that the patient should call her the next time he sees the business rival. This can worsen the patient's condition. p. 209, Box 12.3

The nurse is performing an assessment of geriatric patients in a community health care center. The nurse reports that one of the patients has schizophrenia. Which statement made by the patient while interacting with the nurse supports the nurse's assessment? "Every morning I enjoy the humming of birds; it relaxes me." "Every day my friends wait for me in front of my gate for our morning walk." "Every day birds sing songs for me and spread flowers on the path where I walk." "Everyone feels as if I am a burden to them; I would like to put an end to their problem."

"Every day birds sing songs for me and spread flowers on the path where I walk." Patients with schizophrenia have delusions of self-importance and state false events related to them, like birds singing songs for them and spreading flowers on their path. The statement that every morning the patient enjoys the humming of birds indicates that the patient has no impaired perception and is able to connect with reality. The statement that every morning the patient's friends wait for him or her is normal. The statement that everyone feels the patient is a burden indicates that the patient feels worthless and has suicidal intentions. It does not indicate schizophrenic symptoms. p. 198, Table 12.1

The nurse demonstrates an understanding of the most common comorbid condition observed in a patient with schizophrenia when asking, "Would you describe yourself as being depressed?" "How often do you drink enough alcohol to get drunk?" "How old were you when you became sexually active?" "Have you ever been diagnosed with an eating disorder?"

"How often do you drink enough alcohol to get drunk?" About 50% of patients with schizophrenia have a co-occurring substance abuse disorder, most commonly alcohol or cannabis. Assessing alcohol consumption patterns will help identify this comorbid condition. Eating disorders generally are not observed in patients with schizophrenia. Sexual habits are not generally viewed as being abnormal in the patient with schizophrenia. Although depression may occur, it is not a primary comorbid condition. p. 193

Which statement by a person with paranoid schizophrenia most clearly indicates that the antipsychotic medication is effective? "My medicine is working fine. I'm not having any problems." "I used to hear scary voices but now I don't hear them anymore." "Sometimes it's hard for me to fall asleep, but I usually sleep all night." "I think some of the staff members don't like me. They're mean to me."

"I used to hear scary voices but now I don't hear them anymore." Auditory hallucinations are a common manifestation of paranoid schizophrenia, so their absence is an indicator of medication effectiveness. "My medicine is working fine. I'm not having any problems" and "Sometimes it's hard for me to fall asleep, but I usually sleep all night" are too vague. "I think some of the staff members don't like me. They're mean to me" indicates paranoid thinking. p. 209, Box 12.3

A patient diagnosed with schizophrenia states, "My, oh my. My mother is brother. Anytime now it can happen to my mother." How will the nurse respond to the patient's statement? "I will get you an as-needed medication for agitation." "You are confused. I will take you to your room to rest awhile." "You are having problems with your speech. You need to try harder to be clear." "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

"I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?" The guidelines that are useful in communicating with a patient with disorganized or bizarre speech are to place the difficulty in understanding on the nurse, not the patient, and look for themes that may be helpful in interpreting what the patient wants to say. Telling the patient to try harder to be clearer is unrealistic because the patient would be unable do this. Taking the patient to his or her room or getting the patient medication are not useful options in communicating with this patient and attempting to find common themes. p. 208

A patient is presenting with behaviors that indicate anger. When approached, the patient states harshly, "I'm fine! Everything's great." Which response should the nurse provide to the patient? "Okay, but we are all here to help you, so come get one of the staff if you need to talk." "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." "I don't believe you. You are not being truthful with me." "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"

"It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?" This response uses the therapeutic technique of clarifying; it addresses the difference between the patient's verbal and nonverbal communication and encourages sharing of feelings. The other options do not address the patient's obvious distress or are confrontational and judgmental. None of the other options provides this support.DIF: Cognitive Level: Analyze (Analysis)REF: pages 7-9TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

When a patient diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be "You are safe here. This is a locked unit, and no one can get in." "It must be frightening to think something is going to harm you." "Why do you think someone or something is going to harm you?" "I do not believe I understand the word volmers. Tell me more about them."

"It must be frightening to think something is going to harm you." The correct response focuses on the patient's feelings and neither directly supports the delusion nor denies the patient's experience. Assuring the patient that he or she is safe gives global reassurance. Asking for more details encourages elaboration about the delusion. Asking why is asking for information that the patient will likely be unable to provide. p. 209, Box 12.4

Consider the nurse-patient relationship on an inpatient psychiatric unit. Which of the following statements made by the nurse reflects an accurate understanding of when the issue of termination should first be discussed? You are being discharged today, so I'd like to bring up the subject of termination—discussing your time here and summarizing what coping skills you have attained." "I haven't met my new patient yet, but I am working through my feelings of anxiety in dealing with a patient who wanted to kill herself." "Now that we are working on your problem-solving skills and behaviors you'd like to change, I'd like to bring up the issue of termination." "Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."

"Now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationship—the termination phase, the preorientation phase, and the working phase.DIF: Cognitive Level: Analyze (Analysis)REF: page 18TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

Which statement by a family member of a person diagnosed with schizophrenia demonstrates effective learning about the disease? "The disease probably resulted from the mother's smoking during pregnancy. Nicotine is actually a neurotransmitter." "If our family had more money, we could afford the promising psychoneuroimmunologic treatments available in other countries." "The disease could be cured if our politicians and laws allowed for more stem cell research. Adult stem cells hold so much promise." "The disease probably was caused by problems with several genes. These genes cause changes in how certain brain chemicals work."

"The disease probably was caused by problems with several genes. These genes cause changes in how certain brain chemicals work." The outcome statement indicates that the person understands the basic information about causative factors of schizophrenia. Rationalizing the use of stem cell research, blaming the problem on the mother's smoking behavior, and having funds to afford alternative treatments do not indicate an understanding about the mental disorder. p. 194

A young adult is hospitalized with schizophrenia. The parents are distraught and filled with guilt. What would be an appropriate nursing response? "I'll recommend some excellent websites to learn about schizophrenia and other mental illnesses." "Look on the bright side. With the right medications and treatment, this disease can be cured." "There are many theories about the cause of schizophrenia, but this illness is not your fault." "Does anyone in your family have mental illness? Schizophrenia is a genetically transmitted disease."

"There are many theories about the cause of schizophrenia, but this illness is not your fault." It is important for the nurse to give accurate information without adding to the parent's emotional burden. There are many theories about the etiology of schizophrenia; asking whether anyone in the family has schizophrenia is not a therapeutic statement and may induce guilt. Telling the family to look on the bright side is not realistic and does not respond to their feelings. Recommending websites for research is an incorrect response because the parents are not ready to learn details about mental illness. pp. 194-196

The nurse teaches the parents of an adolescent who was diagnosed with schizophrenia about comorbidity. What does the nurse include in the teaching? "Watch your child for signs of substance abuse." "Make sure your child does not become dehydrated." "With schizophrenia, your child will not experience any depression." "Contact the healthcare provider immediately if your child has anxiety."

"Watch your child for signs of substance abuse." Substance use disorders involving alcohol, marijuana, and nicotine occur in nearly half of the people who are diagnosed with schizophrenia. Substance use is linked to higher rates of treatment nonadherence. Schizophrenia may cause polydipsia, which is a compulsive drinking of excess fluids, not dehydration. Depression frequently co-occurs in individuals with schizophrenia. Anxiety co-occurs with schizophrenia, but it is not necessary to contact the healthcare provider immediately if these symptoms present. p. 193

A patient with schizophrenia tells the nurse he or she has discontinued the pharmacological treatment plan because the symptoms are cured. Which is the best response by the nurse? "It's fine to stop your medication since you are in control of your own treatment." "It is normal to want to stop taking medication, but think about how much better it is making you." "You are experiencing something called anosognosia, which means it is difficult to realize you need to continue with treatment." "If you stop taking your medication, then you must promise to come to weekly appointments so that you can continue to be monitored."

"You are experiencing something called anosognosia, which means it is difficult to realize you need to continue with treatment." People with schizophrenia are often unable to realize they are ill, a condition known as anosognosia. This can result in the patient stopping treatment or being resistant to continue with treatment. It is important to reassure patients of why they feel as though they no longer need treatment by explaining anosognosia. Telling the patient the medication is making him or her better is ineffective for a patient with disordered thinking, even if it is true. A patient is unlikely to come to weekly appointments if the schizophrenia is not appropriately managed. Although the nurse cannot force adherence, the nurse should explain why the medication is important. p. 200

The nurse care for a patient who has been raped. which of the following actions should be performed first? 1. focus on the here and now 2. refer the patient for crisis counseling 3. determine how the rape occurred 4. assess how the patient has previously responded to trauma

1. focus on the here and now first action is to assist patient in determining immediate needs

The nurse expects which of the following medications to be ordered for a patient experiencing alcohol withdraw delirium? 1. phenobarbital and chlordiazeproxide 2. disulfiram and chlorpromazine 3. disulfiram and barbiturates 4. tricyclics and sedatives

1. phenobarbital and chlordiazepoxide anticonvulsants are used for delirium tremens sedation used to control anxiety and agitation, anticonvulsants prevent withdrawal seizures

The parent comes to the mental health clinic seeking help to cope with a defiant teenager who is abusing alcohol and drugs. which question should the nurse ask first? 1. what seems to be the problem 2. what do you think you can do 3. you must feel very angry about this 4. help is available for you

1. what seems to be the problem? important to clearly identify the problem, which is the first step in an intervening crisis

The nurse finds one patient screaming at the roommate "you are always meddling in my side of the room and snooping around my property. I can't stand you anymore" The nurse should take which action? 1. address both patients saying you both seem very upset at each other 2. address the patient who is hooting and say you sound as if you are angry with your roommate 3. tell both parents we will have to mak a plan to avoid this kind of bickering 4. tell the angry patient you must leave the room immediately because you are out of control

2. address the patient who is shouting and say you sound as if you are angry with your roommate address the dominant member to restore control, trying to diffuse anger out of aggressive patient

The nurse instructs a patient's spouse about how to cope with the patient's anxiety. the nurse determines that teaching is successful if the spouse makes which of the following statements? 1. anxiety is a conscious means of resolving conflict 2. anxiety represents an unconscious conflict of needs 3. it is important to confront my spouse during periods of anxiety 4. anxiety is increased by using defense mechanisms

2. anxiety represents an unconscious conflict of needs root of anxiety is the conflict between expressing unacceptable impulses and the need to hold onto social approval

A client newly diagnosed with paranoid schizophrenia tells the nurse that there are really strange people in the corner of my room laughing at me and saying horrible things. which response by the nurse is most appropriate? 1. i don't see anything and you really have nothing to be worried about 2. i don't hear any voices but I know this is frightening for you 3. what are they saying to you? 4. sometimes when people are upset their imagination plays tricks on them

2. i don't hear any voices but i know this is frightening for you the nurse helps the patient separate fantasy from reality

When caring for a patient after ECT it is MOST important for the nurse to take which action? 1. encourage the patient to turn from side to side 2. remind the patient that the memory loss is temporary 3. examine the patient carefully for fractures 4. tell the patient the seizure was very short

2. remind the patient that memory loss is temporary need reassurance the memory loss is temporary, can be frightening and frustrating aspect of treatment

The nurse cares for a client who has taken tricyclic antidepressants for 12 days. which behavior should the nurse be alert for in this client? 1. anger and sarcasm 2. suicidal behaviors 3. withdrawal from reality 4. early morning waking

2. suicidal behaviors once the TCAs start to take effect they will have enough emotional and physical energy to act on suicidal thoughts

The nurse is interacting with the client diagnosed with OCD. the client says to the nurse "i don't understand what is wrong with rules, regulations, and schedules. the nurse understands that the client uses defense mechanisms in order to accomplish which goal 1. to apply a logical approach to a need 2. to provide a feeling of safety and protect the person's sense of self worth 3. to fragment the personality causing mental illness to bring suppressed material into awareness

2. to provide a feeling of safety and protect the person's sense of self worth ego defense mechanisms provide a feeling of self worth by keeping painful unconscious material out

When intervening with the client who is in a state of crisis which statement by the nurse most effectively helps the client cope? 1. why is it that you feel so upset in this situation 2. what have you done when you feel this anxious before 3. there was no way to prevent this from happening 4. it seems as if this situation is very stressful for you

2. what have you done when you feel this anxious before? helps establish coping methods that have helped client in the past

The nurse understands as the primary problem experienced by the client diagnosed with schizophrenia is? 1. split personality 2. compulsive behavior pattern 3. difficulty forming relationships 4. acting out behavior patterns

3. difficulty forming relationships due to inability to trust others is main problem of schizophrenia

Then ruse plans care for a patient diagnosed with antisocial personality disorder the nurse understands that the purpose of group therapy for the patient is to 1. provide ezra time to explore the patient's past 2. demonstrate acceptance of the patient and his behavior 3. set limit on the patient in a non punitive manner 4. encourage sublimation of the patients leadership potential

3. set limits on the patient in a non punitive manner patients with antisocial generally mistrust others and their motivators, leads to manipulative acting out behavior

The nurse cares for a cienet diagnosed with OCD the nurse observes that the patient has difficulty getting to lunch on time because of hand washing ritual. which of the following statements by the nurse is best? 1. starting tomorrow you can eat in your room 2. i know you are feeling anxious but it is important to eat properly 3. tomorrow i will call you 15 minutes earlier to help you get ready in time 4. it is important to discuss this with your doctor

3. tomorrow, i will call you 15 minutes earlier to help you get ready nurses set aside the necessary time for the ritual and communicates acceptance of behavior

Fluphenizene is ordered for the client. if the client develops tar dive dyskinesia, the nurse expects the client to exhibit which findings? 1. tremors and unsteady gait 2. tingling sensations in the extremities and stiffness 3. shuffling and pacing 4. bizarre facial movements and difficulty swallowing

4. bizarre facial movements and difficulty in swallowing protrusion of the tongue, lip smacking, and difficulty swallowing are characteristics

The nurse observes for signs of Korsafkoff's psychosis. the nurse expects the patient to exhibit which? 1. seizures 2. diplopia 3. nystagmus 4. confabulation

4. confabulation in order to fill memory gaps the patient confabulates or invents or elaborates improbable happenings

During group therapy on the unit one client seldom speaks. one morning the client listens intensely and maintains eye contact with another client who speaks about depression but the quiet client still doesn't speak. which response by the nurse is best? 1. you are both sad now but is better to have a positive view to share 2. why are you looking that way you seem very upset 3. express yourself verbally so that the group understands 4. it seems as if you have some feelings about what is being said

4. it seems as if you have some feelings about what is being said conveys to the client that the nurse is following the clients feelings and is interested in what the client has to say

The nurse meets with the client on the psych unit when another client diagnosed with antisocial personality disorder walks in to the room and sits down. which response by the nurse is best? 1. this client and I are taking if you like to sit with us for a while you have to remain quiet. 2. how do you feel about another client joining us 3. do you have something you would like to discuss 4. right now we are talking please leave this room and ill talk to you alter

4. right now we are talking please leave this room and ill talk to you later this client must be made to realize that the client cannot infringe on another client's right to privacy and time with the nurse

the nurse cares for clients in the outpatient clinic. a client relates to the nurse "i travel only by train because I'm terrified of flying. the nurse understands that the phobic client is most likely to respond with what intervention? 1. major tranquilizers 2. insight oriented therapy 3. crisis intervention 4. systemic desensitization

4. systemic desensitization enables client to encounter the phobic object gradually while using relaxation techniques

1. Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia? a. Always afraid another student will steal her belongings. b. An unusual interest in numbers and specific topics. c. Demonstrates no interest in athletics or organized sports. d. Appears more comfortable among males.

A

2. Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia? a. Screening a group of males between the ages of 15 and 25 for early symptoms. b. Forming a support group for females aged 25 to 35 who are diagnosed with substance use issues. c. Providing a group for patients between the ages of 45 and 55 with information on coping skills that have proven to be effective. d. Educating the parents of a group of developmentally delayed 5- to 6-year-olds on the importance of early intervention.

A

The causation of schizophrenia currently is understood to be A combination of inherited and nongenetic factors Deficient amounts of the neurotransmitter dopamine Excessive amounts of the neurotransmitter serotonin Stress related and ineffective stress management skills

A combination of inherited and nongenetic factors Causation is a complicated matter. Schizophrenia most likely occurs as a result of a combination of inherited genetic factors and extreme nongenetic factors (e.g., viral infection, birth injuries, and nutritional factors) that can affect the genes governing the brain or directly injure the brain. Changes in dopamine and serotonin are signs of schizophrenia but not thought to be the cause. Stress and ineffective stress management are risk factors but not thought to cause schizophrenia. pp. 194-196

The nurse is caring for four patients with schizophrenia. Which patient is exhibiting grandiose delusions? A patient who believes that his or her brain is rotting A patient who believes he or she is the President of the United States A patient who believes his or her food in the hospital is being poisoned A patient who believes the healthcare provider has romantic feelings for the patient

A patient who believes he or she is the President of the United States Grandiose delusions involve believing that one is a powerful or important person, such as the President of the United States. Believing that food is being poisoned is an example of persecutory delusions. Believing that the brain is rotting away is an example of somatic delusions. Believing that the healthcare provider has romantic feelings for the patient is an example of erotomanic delusions. p. 198

The nurse understands that which patients have risk factors for schizophrenia? A patient who was raised in an affluent environment A patient who was a victim of childhood sexual abuse A patient who had a concussion from a sports accident A patient whose mother had an infection during the pregnancy A patient who was exposed to tetrachloroethylene in drinking water

A patient who was a victim of childhood sexual abuse A patient whose mother had an infection during the pregnancy A patient who was exposed to tetrachloroethylene in drinking water A maternal infection is a prenatal risk factor for schizophrenia. Exposure to tetrachloroethylene in drinking water is an environmental risk factor for schizophrenia. Childhood sexual abuse is a psychological risk factor for schizophrenia. Concussions do not predispose people to schizophrenia. Being raised in poverty, not affluence, is a risk factor for schizophrenia. p. 194

Of the following environments, which would be most conducive to a therapeutic session? The nurses' station A table in the coffee shop A quiet section of the day room The utility room

A quiet section of the day room Of the options provided, a quiet corner of the day room offers the safest, quietest, most private environment for a therapeutic encounter. None of the other options offer these characteristics.REF: 140-149

The achievement of long-term treatment goals for a patient diagnosed with schizophrenia is reliant upon which factor? A trusting nurse-patient relationship Patient adherence to treatment plan Patient achievement of accepted cognitive and social skills Medication therapy that is reviewed regularly for effectiveness Patient interaction with community-based therapeutic services

A trusting nurse-patient relationship Patient adherence to treatment plan Medication therapy that is reviewed regularly for effectiveness Patient interaction with community-based therapeutic services Effective long-term care of persons with schizophrenia relies on a three-pronged approach: medication administration/adherence, relationships with trusted care providers, and community-based therapeutic services. Cognitive and social skills are not relevant. p. 203

9. 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. c. Administer a medication such as benztropine IM to correct this dystonic reaction. d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. e. Hold his medication for now and consult his prescriber when he comes to the unit later today.

A,B

2. Which statement made by the patient demonstrates an understanding of the effective use of newly prescribed lithium to manage bipolar mania? Select all that apply. a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day." b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider." c. "Lithium may help me lose the few extra pounds I tend to carry around." d. "I take my lithium on an empty stomach to help with absorption." e. "I've already made arrangements for my monthly lab work."

A,B,E

1. Which nursing response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar and her support system? Select all that apply. a. "Remember that alcohol and caffeine can trigger a relapse of your symptoms." b. "Due to the risk of a manic episode, antidepressant therapy is never used with bipolar disorder. c. "It's critical to let your healthcare provider know immediately if you aren't sleeping well." d. "Is your family prepared to be actively involved in helping manage this disorder?" e. "The symptoms tend to come and go and so you need to be able to recognize the early signs."

A,C,D,E

5. Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select all that apply. a. Monitor the patient's vital signs frequently. b. Keep the patient distracted with group-oriented activities. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient.

A,C,D,E

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

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? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

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: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

ANS: A The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection.

A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

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: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium.

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? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

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? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety.

During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

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. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

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: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

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: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety.

A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

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: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

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? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

ANS: C Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.

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? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

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? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

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? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

ANS: D In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

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? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

Which symptom would NOT be assessed as a positive symptom of schizophrenia? Idea of reference Affective flattening Auditory hallucinations Delusion of persecution

Affective flattening Positive symptoms are those symptoms that should not be present, but are. They include hallucinations, delusions, bizarre behavior, and paranoia and are referred to as florid symptoms. Affective flattening is one of the negative symptoms that contribute to rendering the person inert and unmotivated. pp. 197-199, 201, Table 12.2

During a clinical interview the client falls silent after disclosing that she was sexually abused as a child. The nurse should engage in which intervention in response to the client's silence? Quickly break the silence and encourage the client to continue. Reassure the client that the abuse was not her fault. Reach out and gently touch the client's arm. Allow the client to break the silence.

Allow the client to break the silence. Silence is not a "bad" thing. It gives the speaker time to think through a point or collect his or her thoughts. None of the other options will assist with further communication with this client.REF: 141-142

A patient who has been receiving antipsychotic medication for 6 weeks tells the nurse that the hallucinations are nearly gone and that concentration has improved. When the patient reports flulike symptoms, including a fever and a very sore throat, the nurse should Consider recommending a change of antipsychotic medication Arrange for the patient to have blood drawn for a white blood cell count Suggest that the patient take something for his or her fever and get extra rest Advise the health care provider that the patient should be admitted to the hospital

Arrange for the patient to have blood drawn for a white blood cell count Antipsychotic medications may cause agranulocytosis, the first manifestation of which may be a sore throat and flulike symptoms. Agranulocytosis with infection could be life threatening, so recommending rest does not address the underlying problem. The patient may not need to be admitted to the hospital but should have blood drawn to guide the next step. A nurse would not recommend a change of medication. The medication has been effective and might not need to be changed. p. 216, Table 12.6

A desired outcome for a patient diagnosed with schizophrenia who is experiencing auditory hallucinations would be that the patient will Ask for validation of reality Describe content of hallucinations Demonstrate a cool, aloof demeanor Identify prodromal symptoms of disorder

Ask for validation of reality Beginning to question his or her own altered perceptions by seeking input from staff is highly desirable. pp. 203-205, Case Study and Nursing Care Plan

Which communication techniques should the nurse use with a client who has been identified as having difficulty expressing thoughts and feelings? Using emotionally charged words and gestures Offering opinions and avoiding periods of silence Asking closed-ended questions requiring "yes" or "no" answers Asking open-ended questions and seeking clarification

Asking open-ended questions and seeking clarification Open-ended questions give the client the widest possible latitude in answering. Also, the client can take the lead in the interview. Seeking clarification helps the client clarify his or her own thoughts and promotes mutual understanding. None of the options provide this support.REF: 142-143

What intervention is focused on supporting the overall goal of the acute phase of illness for a psychotic patient? Evaluating the patient's understanding of the diagnosis of schizophrenia. Assessment of patient regarding the existence of command hallucinations. Administration of medication therapy prescribed for negative symptoms of schizophrenia. Encouraging the patient to be independent regarding self-care needs. Providing a low-stimulation environment to minimize aggressive behavior.

Assessment of patient regarding the existence of command hallucinations. Providing a low-stimulation environment to minimize aggressive behavior. For the acute phase, the overall goal is patient safety and stabilization. Phase II focuses on helping the patient understand the illness and treatment, becoming stabilized on medications, and controlling or coping with symptoms. Outcome criteria for phase III focuses on maintaining achievement, adhering to treatment, preventing relapse, and achieving independence and a satisfactory quality of life. p. 201

A patient diagnosed with schizophrenia is most likely to experience which type of hallucination? Visual Tactile Auditory Olfactory

Auditory Patients diagnosed with schizophrenia may experience hallucinations arising out of any of the senses; however, auditory hallucinations are experienced by 60% of people with schizophrenia at some time during their lives. Visual hallucinations more commonly are associated with substance abuse and withdrawal. Tactile and olfactory hallucinations are rare. p. 198

The type of altered perception most commonly experienced by patients with schizophrenia is Delusions Illusions Tactile hallucinations Auditory hallucinations

Auditory hallucinations Hallucinations, especially auditory hallucinations, are the major example of alterations of perception in schizophrenia. They are experienced by as many as 90% of individuals with schizophrenia. pp. 198-199

A term is a synonym for the characteristic of genuineness? Respect Empathy Authentic Positive regard

Authentic Genuineness refers the nurse's ability to be open, honest, and authentic in interactions with patients. It is the ability to meet others person-to-person without hiding behind roles. While positive characteristics, none of the other options related to genuineness.REF: 133

10. 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: a. Generally good health despite the mental illness. b. An aversion to drinking fluids. c. Anxiety and depression. d. The ability to express his needs.

C

7. Ted, a former executive, is now unemployed due to manic episodes at work. He was diagnosed with bipolar I 8 years ago. Ted has a history of IV drug abuse, which resulted in hepatitis C. He is taking his lithium exactly as scheduled, a fact that both Ted's wife and his blood tests confirm. To reduce Ted's mania the psychiatric nurse practitioner recommends: a. Clonazepam (Klonopin) b. Fluoxetine (Prozac) c. Electroconvulsive therapy (ECT) d. Lurasidone (Latuda)

C

7. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes? a. "I know you say you hear voices, but I cannot hear them." b. "Stop listening to the voices, they are NOT real." c. "You say you hear voices, what are they telling you?" d. "Please tell the voices to leave you alone for now."

C

A nurse understands that antipsychotic drugs may sometimes have toxic effects. The nurse suggests to the patient's guardians to give the patient foods rich in carbohydrates and protein and to ensure that the patient undergoes a liver function test every 6 months. Which of these toxic effects was the nurse thinking about when making such a suggestion? Weight gain Hyperpyrexia Agranulocytosis Cholestatic jaundice

Cholestatic jaundice Antipsychotics may cause cholestatic jaundice because of impaired liver function. Hence, a liver function test should be performed every 6 months. The patients must be given foods rich in carbohydrates and protein in order to enhance liver function. Hyperpyrexia is an extreme elevation of the body temperature and is a medical emergency. Weight gain is a common side effect with some antipsychotics and the drug may need to be changed. Agranulocytosis is caused by a reduction in white blood cell count. p. 216, Table 12.6

When discussing her husband, a client shares that "I would be better off alone. At least I would be able to come and go as I please and not have to be interrogated all the time." What therapeutic communication technique is the nurse using when responding, "Are you saying that things would be better if you left your husband?" Focusing Restating Reflection Clarification

Clarification Clarification verifies the nurse's interpretation of the client's message. None of the other options are associated with the verification of the client's meaning.REF: 142

After a client discusses his/her relationship with his/her father, the nurse asks, "Tell me if I'm correct that you feel dominated and controlled by him?" What is the purpose of the nurse's question? Eliciting more information Encouraging evaluation Verbalizing the implied Clarifying the message

Clarifying the message Clarification helps the nurse understand and correctly interpret the client's message. It gives the client the opportunity to correct misconceptions. This is not the purpose of any of the other options.REF: 142

4. 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? a. Her memory problems will likely decrease. b. Depressive episodes should be less severe. c. She will probably enjoy social interactions more. d. She should experience a reduction in hallucinations.

D

6. 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: a. Favorable with medication b. In the relapse stage c. Improvable with psychosocial interventions d. To have a less positive outcome

D

8. When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that: a. Medications provided are ineffective. b. Nurses are trying to control their minds. c. The medications will make them sick. d. They are not actually ill.

D

Which symptom seen in a patient with schizophrenia can be categorized as a positive symptom? Delusions Dysphoria Loss of motivation Impaired judgment

DELUSIONS The behavioral traits not normally found in healthy patients are called positive symptoms of schizophrenia. They include delusions, hallucinations, bizarre behavior, and paranoia. The behaviors that the patient lacks compared with healthy people are negative symptoms, such as loss of motivation and alogia (poverty of thought or inability to speak). Impaired judgment and illogical thinking are the cognitive symptoms associated with schizophrenia. Dysphoria and suicidal intentions are affective symptoms of schizophrenia. Affective symptoms involve emotions and their expression. pp. 197, 201, Table 12.2

The outcome of the nurse's expressions of sympathy instead of empathy toward the client often leads to which outcome? Enhanced client coping Lessening of client emotional pain Increased hope for client improvement Decreased client communication

Decreased client communication Sympathy and the resulting projection of the nurse's feelings limit the client's opportunity to further discuss the problem. The remaining options are positive outcomes.REF: 133

What question would the nurse consider when determining the ability of a patient diagnosed with schizophrenia to ensure his or her own personal safety? Is the patient able to read and write? Does the patient appear fed and hydrated? Is the patient attending to personal hygiene? Is the patient appropriately dressed for the weather? Does the patient appear to have mobility problems?

Does the patient appear fed and hydrated? Is the patient attending to personal hygiene? Is the patient appropriately dressed for the weather? Does the patient appear to have mobility problems? The nurse would assess the patient's ability to ensure personal safety by asking questions concerning adequate food and fluid intake, hygiene and self-care, ability to move about safely (e.g., falls, walking into traffic), impulse control and judgment, and safe dress for weather conditions. Ability to read and write is not relevant. p. 201

Which diagnostic finding associated with structural brain anomalies has been observed in patients diagnosed with schizophrenia? Increased cortical thickness Increased frontal lobe volume Enlargement of the lateral cerebral ventricles Reduced connectivity in various brain regions Increased size of the sulci (fissures) on the brain's surface

Enlargement of the lateral cerebral ventricles Reduced connectivity in various brain regions Increased size of the sulci (fissures) on the brain's surface Brain imaging techniques provide substantial evidence that some people with schizophrenia have structural brain abnormalities that include the following: enlargement of the lateral cerebral ventricles, reduced frontal lobe volume, increased size of the sulci (fissures) on the surface of the brain, reduced cortical thickness, and reduced connectivity in various brain regions. p. 194

The nurse is caring for a patient who was diagnosed with schizophrenia 16 months ago. It has been nearly 10 months since the last psychotic episode. How does the nurse specify this disease progression? First episode, currently in full remission First episode, currently in acute episode First episode, currently in partial remission Multiple episodes, currently in acute episode

First episode, currently in full remission The patient who does not present with any signs or symptoms of schizophrenia for a period of time after a previous episode is considered to be first episode, currently in full remission. An acute episode is a time in which the symptoms criteria are fulfilled. Partial remission means that there is an improvement after a previous episode, and the criteria of the disorder are only partially fulfilled. This patient is not displaying multiple episodes, which indicates two episodes. p. 193

Gynecomastia, amenorrhea, and galactorrhea are side effects most often associated with which medications? Anticholinergic medications Third-generation antipsychotics Second-generation (atypical) antipsychotics First-generation (conventional) antipsychotics

First-generation (conventional) antipsychotics First-generation antipsychotic medications commonly have side effects that relate to sexual dysfunction. These side effects include gynecomastia (enlarged breast tissue), amenorrhea (absence of menstruation), and galactorrhea (discharge from nipples). The incidence of these side effects is much less in second- and third-generation antipsychotic medications. Anticholinergic medications have side effects of constipation and blurred vision.

The nurse would address which of the following goals in attempting to establish a therapeutic nurse-client relationship? -Helping patients examine self-defeating behaviors and test alternatives -Promoting self-care and independence -Providing the client with opportunities to socialize -Assisting patients with problem solving to help facilitate activities of daily living -Facilitating communication of distressing thoughts and feelings

Helping patients examine self-defeating behaviors and test alternatives Promoting self-care and independence Assisting patients with problem solving to help facilitate activities of daily living Facilitating communication of distressing thoughts and feelings Addressing the client's need to socialize is not one of the goals of establishing a therapeutic relationship. The other options are goals addressed in a therapeutic relationship.REF: 125

A patient has had schizophrenia for the past 15 years and is treated with first-generation antipsychotics and bromocriptine. The nurse suspects that the patient is not following the schedule for taking bromocriptine regularly. What complications does the nurse evaluate in the patient during assessment? Neutropenia Hyperpyrexia Muscular rigidity Sexual dysfunction Deep vein thrombosis

Hyperpyrexia Muscular rigidity Deep vein thrombosis Neuroleptic malignant syndrome is caused by excessive reduction in dopamine functions as a result of receptor blockage. Patients with schizophrenia who take first- and second-generation antipsychotic drugs for 15 to 20 years may develop neuroleptic malignant syndrome. Patients are prescribed bromocriptine to treat neuroleptic malignant syndrome. The nurse should evaluate muscular rigidity in patients because neuroleptic malignant syndrome is characterized by muscular rigidity, hyperpyrexia, and deep vein thrombosis. Neutropenia is caused by agranulocytosis and is seen in patients who are treated with clozapine, a second-generation antipsychotic drug. Sexual dysfunction is not a characteristic of neuroleptic malignant syndrome. It is a common side effect of antipsychotic drugs. pp. 216, 217, Table 12.6

What electrolyte imbalance can be seen in patients who have schizophrenia who are experiencing polydipsia? Hypokalemia Hypocalcemia Hyponatremia Hypercalcemia

Hyponatremia In patients with schizophrenia, polydipsia is seen as a result of dry mouth. Patients experience excessive thirst because of antipsychotic drugs and drink a lot of water. Polydipsia is characterized by hyponatremia, confusion, and severe symptoms of schizophrenia. It is caused by the inability of the kidneys to filter excess fluids. Hypokalemia is a condition that produces reduced levels of potassium, which can be caused by antibiotics. Hypocalcemia refers to increased levels of calcium as a result of a deficiency of vitamin D or defective absorption. It can also happen because of impaired metabolism of vitamin D in the body. Hypercalcemia is an increase in levels of calcium seen during hyperparathyroidism. pp. 198-199

Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. A social relationship is instituted for the main purpose of exploring one member's feelings and issues; a therapeutic relationship is instituted for the purpose of friendship. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. In a social relationship, communication is usually deep and evaluated; in a therapeutic relationship, communication remains on a more superficial level, allowing patients to feel comfortable.

In a social relationship, both parties' needs are met; in a therapeutic relationship, only the patient's needs are to be considered. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship, solutions are discussed but are only implemented by the patient. The other options describe the opposite meanings of social and therapeutic relationships.DIF: Cognitive Level: Analyze (Analysis)REF: pages 4, 5TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

The nurse believes a patient may have schizophrenia based on which signs and symptoms? Headaches Depression Incoherence Hearing voices Withdrawn behavior

Incoherence Hearing voices Withdrawn behavior Hearing voices is an auditory hallucination, which is a symptom of psychosis that could be present with schizophrenia. Incoherence is a type of disorganized speech, which is also a symptom of schizophrenia. Withdrawn behavior is a sign of psychosis and schizophrenia. Headaches are general symptoms that could indicate many types of diseases or disorders, not specific to schizophrenia. Depression is not an initial symptom of schizophrenia or psychosis, but may co-occur with schizophrenia. p. 192

Which of the following would indicate paranoia in a patient with schizophrenia? Feelings of superiority to others False perception of environment Irrational fear of harm from others Impaired ability to think abstractly

Irrational fear of harm from others Patients with paranoia experience an irrational fear of harm from others that ranges from mild to severe. The patients suspect that others want to harm them, and they react defensively toward caregivers and other patients. Feelings of superiority are seen in patients with delusions. Patients with derealization have false perceptions of the environment and may misinterpret the stimuli in the environment. An impaired ability to think abstractly is seen in patients with disorders of concrete thinking. p. 198

A patient diagnosed with schizophrenia reports voices stating the patient is a horrible human being. The nurse can correctly assume that the hallucination May signal seizure onset Is a retained memory fragment Derives from neuronal impulse misfiring Is a projection of the patient's own feelings

Is a projection of the patient's own feelings One theory about derogatory hallucinations is that the content is a projection of the individual's feelings about him- or herself. The derogatory hallucinations are an extension of the strong feelings of rejection and lack of self-respect experienced by the individual during the prodromal period. pp. 198-199

The nurse is confident that an individual prescribed antipsychotic medication has been experiencing medication efficacy and showing insight when the patient Can restate the importance of medication compliance Has been attending regularly prescribed therapy sessions No longer experiences hallucinations or delusional thinking Is able to assess effectively the reality of his or her thinking processes

Is able to assess effectively the reality of his or her thinking processes Attaining insight is demonstrated by the ability to make reliable reality checks. This takes 6 to 18 months and depends on medication efficacy and ongoing support. Although attending therapy sessions and restating the importance of medication compliance are positive behaviors, they do not show insight because there is no critical thinking involved. The lack of hallucinations or delusional thinking reflects positive outcomes but not necessarily insight because there is no critical thinking involved. p. 197

A patient with schizophrenia is prescribed clozapine. Which physiological conditions of the patient should the nurse monitor? SELECT ALL THE APPLY Liver function Kidney function Total red blood cell count Total white blood cell count Total water intake and output

Liver function Total white blood cell count Agranulocytosis is the most common symptom of clozapine. It is characterized by a reduced white blood cell count (less than 3000/mm 3) and liver impairment. Hence, the nurse should frequently monitor the liver function and total white blood cell count. Clozapine does not have an effect on the kidneys; therefore the total water intake and output and kidney function do not need to be monitored. Clozapine reduces white blood cell count but does not affect red blood cell count; therefore, it is not required to monitor red blood cell count. pp. 214, 216, Table 12.6

A patient's dose of haloperidol was increased earlier today. The patient now is experiencing laryngeal dystonia. What is the nurse's priority action? Document the finding. Maintain a patent airway. Offer oral fluids to the patient. Engage the patient in an alternative activity.

Maintain a patent airway. Laryngeal dystonia is associated with an acute dystonic reaction and may impair the integrity of the patient's airway. The nurse will document the events after they are managed. Oral fluids could be aspirated. Immediate nursing action is indicated; it would be inappropriate to try to engage the patient in an alternate activity. p. 215, Table 12.6

Which intervention will improve outcomes for a patient diagnosed with schizophrenia? SELECT ALL Managing the titrating of the patient's medication. Assessing the patient for suicidal ideations regularly. Screening the patient for involuntary motor movement. Encouraging patient involvement in self-help support groups. Minimizing patient stress by limiting involvement in the goal-setting process.

Managing the titrating of the patient's medication. Assessing the patient for suicidal ideations regularly. Screening the patient for involuntary motor movement. Encouraging patient involvement in self-help support groups. Patient care and outcomes can be improved by including the use of evidence-based performance measures regarding assessment, treatment, and evaluating care, including the use of effective, affordable medications titrated to effective dosages, such as second-generation antipsychotics for persons with prominent negative symptoms, assessment for risk of suicide, screening for involuntary movement and metabolic syndrome, and promoting involvement in self-help and support groups. Patients always should be involved in the treatment plan to the extent of their abilities. p. 218

What area of instruction should the nurse include in the education of a family with a member who has been diagnosed with schizophrenia? SELECT ALL THE APPLY Medication side effects Stress as a psychotic trigger Relapse prevention strategies Need for family to take over the management of care Family's role in achieving positive treatment outcomes

Medication side effects Stress as a psychotic trigger Relapse prevention strategies Family's role in achieving positive treatment outcomes Education is essential and includes teaching the patient and family about the illness: causes, medications, and side effects, coping strategies, what to expect, and relapse prevention. This knowledge and skill help the patient and family to appreciate the impact of stress and the importance of treatment to a good outcome. The patient who returns to a warm, concerned, and supportive environment is less likely to experience relapse. The patient should always be involved in the management of his or her care to the extent of his or her abilities. p. 210, Box 12.5

A nurse on the psychiatric unit has a past history of alcoholism and has regular meetings with a mentor. Which statement made to the nurse's mentor would indicate the presence of countertransference? "My patient is being discharged tomorrow. I provided discharge teaching and stressed the importance of calling the help line number should she become suicidal again." "My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" "My patient started drinking after 14 years of sobriety. We are focusing on his treatment plan of attending AA (Alcoholics Anonymous) meetings five times a week after discharge." "My patient, is an elderly woman with depression. She calls me by her daughter's name because she says I remind her of her daughter."

My patient has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" This statement indicates countertransference; the nurse may be overidentifying with the patient because of a past history of alcoholism. Providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to personal past experiences than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference.DIF: Cognitive Level: Analyze (Analysis)REF: pages 11, 12TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity

Which assessment finding supports the presence of extrapyramidal side effects (EPSs)? Nausea and vomiting Eyes sensitive to light Near constant pacing Hand tremors observable bilaterally Sustained contraction of the neck muscle

Near constant pacing Hand tremors observable bilaterally Sustained contraction of the neck muscle First-generation antipsychotics are dopamine D2 antagonists in both the limbic and motor centers. This blockage of D2 dopamine receptors in the motor areas causes EPSs. Three of the more common EPSs are acute dystonia (acute sustained contraction of muscles, usually of the head and neck), akathisia (psychomotor restlessness evident as pacing or fidgeting, sometimes pronounced and very distressing to patients), and pseudoparkinsonism (a medication-induced, temporary constellation of symptoms associated with Parkinson's disease: tremor, reduced accessory movements, impaired gait, and stiffening of muscles). Nausea and photosensitivity are not considered EPSs. p. 211

A patient diagnosed with residual schizophrenia is uninterested in community activities, lacks initiative, demonstrates both poverty of content and poverty of speech, and seems unable to follow the schedule for taking prescribed antipsychotic medication. The case manager continues to direct care with the knowledge that this behavior most likely is prompted by Personality conflict Neural dysfunction Dependency needs Chronic uncooperativeness

Neural dysfunction Schizophrenia is considered a neurobiological disorder. The course of schizophrenia involves recurrences. With each relapse further deterioration is noted. Residual schizophrenia refers to the disorder when active phase symptoms are no longer present and the individual is left with two or more of the following symptoms: lack of initiative, social withdrawal, impaired role function, marked speech deficits, and odd beliefs. p. 194

A patient is sitting with arms crossed over his or her chest, his or her left leg is rapidly moving up and down, and there is an angry expression on his or her face. When approached by the nurse, the patient states harshly, "I'm fine! Everything's great." Which statement related to communication should the nurse focus on when working with this patient? Verbal communication is always more accurate than nonverbal communication. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.

Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message. Communication is roughly 10% verbal and 90% nonverbal, so nurses must pay close attention to nonverbal cues to accurately assess what the patient is really feeling. The other options are all untrue of verbal and nonverbal communication and are actually the opposite of what is believed of communication.DIF: Cognitive Level: Analyze (Analysis)REF: pages 7-9TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity

A patient with schizophrenia is treated with antipsychotics for 3 months. The nurse reports that the patient has reduced confusion and hallucinations. The health care provider wants to improve the social functioning and withdrawing nature of the patient along with the confusion and hallucination. Which drug would be prescribed to the patient in this phase? Loxapine Olanzapine Fluphenazine Chlorpromazine

Olanzapine Confusion and hallucination are positive symptoms of schizophrenia. Reduced social functioning and withdrawal are the negative symptoms of schizophrenia. Olanzapine is a second-generation antipsychotic. It can treat both positive and negative symptoms of schizophrenia. Chlorpromazine is a first-generation low-potency antipsychotic. Fluphenazine is a first-generation high-potency antipsychotic. Loxapine is a first-generation medium-potency antipsychotic. First-generation antipsychotics treat only positive symptoms of schizophrenia. p. 212, Table 12.5

Which drug can be used to treat alogia, avolition, and anhedonia in schizophrenic patients? Molindone Olanzapine Thiothixene Thioridazine

Olanzapine Olanzapine is a second-generation antipsychotic. It is prescribed to treat both positive symptoms, like hallucination and delusion, and negative symptoms, like alogia, avolition, and anhedonia. Thiothixene is a high-potency first-generation antipsychotic. It is prescribed to treat positive symptoms like hallucination and delusion. Molindone is a medium-potency first-generation antipsychotic. It does not treat alogia, avolition, or anhedonia. Thioridazine is a low-potency first-generation antipsychotic used to treat positive symptoms of schizophrenia. p. 212, Table 12.5

During what stage of the therapeutic nurse-client relationship is a formal or informal contract between the nurse and client established? Preorientation Orientation Working Termination

Orientation Contracting is part of the orientation phase of the relationship. Establishing the operational "rules" provides a foundation for the relationship. This function is not associated with any of the other options.REF: 130-131

An adult with a 6-year history of schizophrenia begins a community rehabilitation program. Select the most appropriate initial outcome for this patient. The patient will Lead the morning exercise group Participate actively in scheduled programming Apply for employment in a local sheltered workshop Report that no auditory hallucinations have occurred

Participate actively in scheduled programming Participation in scheduled activities of the program should occur first. After the patient is accustomed to the program, he or she might lead a group or apply for employment. Hallucinations commonly continue to occur in patients diagnosed with schizophrenia. pp. 203, 210, Box 12.5

The nurse is caring for five patients on a unit who have schizophrenia. Which patients are presenting with alterations in perception? Patient who reports feeling depressed Patient who reports seeing the his or her dead relative Patient who reports hearing babies crying in a quiet room Patient who reports feeling disoriented in the hospital room Patient who reports feeling like ants are crawling on his or her skin

Patient who reports seeing the his or her dead relative Patient who reports hearing babies crying in a quiet room Patient who reports feeling like ants are crawling on his or her skin Hallucinations are alterations in perception and include auditory (hearing the sounds of babies crying), visual (seeing people or things that are not there), and tactile (feeling ants crawling on the skin). Patients who feel disoriented or depressed are experiencing affective signs, not alterations in perception. p. 198

Which statement is true regarding schizophrenia, treatment, and outcomes? If treated quickly following diagnosis, schizophrenia can be cured. Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability.

Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. Unfortunately, in most cases, schizophrenia does not respond fully to available treatments; it leaves residual symptoms and causes varying degrees of dysfunction or disability. Untrue statements about schizophrenia are that it can be cured if treated quickly, it can be managed by receiving treatment only at the time of acute exacerbations, and if patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms. p. 196

A nurse assesses a patient diagnosed with schizophrenia who states, "Aliens are trying to inject me with their DNA." The nurse documents the patient's comment and applies which term? Anosognosia Affective blunting Positive symptoms Negative symptoms

Positive symptoms The patient's comment indicates delusional thinking, which is a positive symptom of schizophrenia. Anosognosia refers to an inability to realize an illness exists. Affective blunting relates to the patient's outward expression of emotion. Negative symptoms include social isolation, anergia, lack of motivation, blunted affect, and inattention to personal hygiene. pp. 197-199, 201, Table 12.2

The nurse is caring for a patient who presents with disorganized thoughts and reports hearing voices that tell him or her to stay home. As a result, the patient has not shown up for work in several weeks and is at risk of losing employment. How does the nurse document this in the patient's chart? Positive symptoms of schizophrenia Negative symptoms of schizophrenia Cognitive symptoms of schizophrenia Affective symptoms of schizophrenia

Positive symptoms of schizophrenia The patient is presenting with positive symptoms of schizophrenia. This includes the presence of something that should not be present, such as hallucinations, delusions, paranoia, disorganized thoughts, and bizarre behaviors. Negative symptoms are the absence of something that should be present. Examples include the inability to enjoy activities or being uncomfortable in social situations. Cognitive symptoms can include subtle or obvious impairment in memory, thinking, and attention. Affective symptoms involve motions and their expressions.

A client tells the nurse "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the client may be experiencing which unconscious emotion? Congruence Empathetic feelings Countertransference Positive transference

Positive transference Transference involves the client experiencing feelings toward a nurse that belong to a significant person in the client's past. If a patient is motivated to work with you, completes assignments between sessions, and shares feelings openly, it is likely the patient is experiencing positive transference. The behavior is not associated with any of the other options.REF: 127-128

The most common course of schizophrenia is an initial episode followed by Complete recovery Continuous deterioration Recurrent acute exacerbations Recurrent acute exacerbations and deterioration

Recurrent acute exacerbations and deterioration Schizophrenia is usually a disorder marked by an initial episode followed by recurrent acute exacerbations. With each relapse of psychosis, an increase in residual dysfunction and deterioration occurs. p. 196

Which statement is accurate regarding the relationship between depression and schizophrenia? Suicide attempts usually occur early in the course of schizophrenia. Antipsychotic medications alleviate symptoms of depression for patients diagnosed with schizophrenia. Regular assessments should occur for both depression and suicide risk in patients diagnosed with schizophrenia. Nicotine use in patients diagnosed with schizophrenia stimulates neurotransmitters, resulting in a decreased incidence of depression and suicide.

Regular assessments should occur for both depression and suicide risk in patients diagnosed with schizophrenia. Almost half of people with schizophrenia will attempt suicide; therefore, assessments for depression and suicide should occur throughout the patient's life. Both depression and suicide attempts can occur at any point in the illness. Antipsychotic medications do not alleviate symptoms of depression for patients diagnosed with schizophrenia. Nicotine use is higher in patients diagnosed with schizophrenia; nicotine stimulates some neurotransmitters, but this does not result in a decreased incidence of depression. p. 193

The nurse is addressing a primary symptom of schizophrenia when Arranging for the patient to attend stress management classes Reinforcing the patient's ability to interrupt intrusive paranoid thoughts Working with the patient to arrive at a budget that allows him or her to live independently Supporting the patient in his or her attempts to stop using alcohol to cope with hallucinations

Reinforcing the patient's ability to interrupt intrusive paranoid thoughts Primary symptoms are ones that are directly caused by the mental illness, such as paranoid thoughts. Stress is a secondary symptom of schizophrenia resulting from stressors related to coping with the illness. A need for assistance while living independently is a secondary symptom of schizophrenia resulting from stressors created by the illness. Alcohol abuse is a secondary symptom of schizophrenia resulting from the use of alcohol to manage the stress of the hallucinations (a primary symptom). p. 193

A distinguishing factor of psychosis is that it Is caused by moderate to severe anxiety Incorporates delusions into an individual's reality Results in a significant misrepresentation of what is real Is dependent on an individual's baseline cognitive function

Results in a significant misrepresentation of what is real Psychosis is disintegrative and involves a significant distortion of reality. Psychosis emerges with the panic level of anxiety. Delusional thinking may not be demonstrated by all psychotic individuals. Cognitive function is not a predisposing factor for the development of psychosis. p. 192

What statement is true regarding schizophrenia? Schizophrenia is a potentially devastating brain disorder. Social behavior and emotions are affected by schizophrenia. This disorder moderately affects the individual's quality of life. The disorder often affects an individual's language and thinking skills. The disorder disturbs a person's ability to determine what is or is not real.

Schizophrenia is a potentially devastating brain disorder. Social behavior and emotions are affected by schizophrenia. The disorder often affects an individual's language and thinking skills. The disorder disturbs a person's ability to determine what is or is not real. Schizophrenia spectrum and other psychotic disorders disturb the fundamental inability to determine what is or is not real. Schizophrenia is a potentially devastating brain disorder that affects a person's thinking, language, emotions, social behavior, and ability to perceive reality accurately. It affects more than 3.5 million people in the United States and is among the most disruptive and disabling of mental disorders. p. 192

Which intervention is directed toward the management of a classic comorbid condition associated with schizophrenia? Screening for possible cocaine abuse Providing nicotine patch therapy as prescribed Monitoring for possible elevated blood glucose levels Scheduling art therapy sessions to facilitate regular attendance Explaining the role contracting for safety has on managing suicidal impulses

Screening for possible cocaine abuse Providing nicotine patch therapy as prescribed Monitoring for possible elevated blood glucose levels Explaining the role contracting for safety has on managing suicidal impulses Comorbid conditions associated with schizophrenia include substance abuse, nicotine dependence, anxiety, depression, and suicide, as well as physical health illnesses, such as diabetes. Although scheduling therapy sessions to facilitate attendance is appropriate, it is not relevant to comorbid conditions associated with schizophrenia. pp. 193-194

Which nursing diagnosis is most applicable to a patient experiencing an acute exacerbation of schizophrenia with predominantly negative symptoms? Disturbed sensory perception related to auditory hallucinations Impaired verbal communication related to associative looseness Risk for other-directed violence related to inability to control hostile impulses Social isolation related to withdrawal and reduced communication with others

Social isolation related to withdrawal and reduced communication with others Negative symptoms include social isolation, anergia, lack of motivation, blunted affect, and inattention to personal hygiene. Associative looseness, auditory hallucinations, and hostile impulses represent positive symptoms. p. 201, Table 12.2

The nurse is caring for a patient with schizophrenia who reports diminishing symptoms and the ability to "remember things clearly again." The healthcare provider determines the patient is ready for outpatient mental health services. The nurse identifies that the patient is in which phase of schizophrenia? Acute Prodromal Stabilization Maintenance

Stabilization The patient with diminishing or stabilizing symptoms with movement toward a previous level of functioning is in the stabilization phase of schizophrenia. The prodromal phase is the first phase in which the patient presents with mild changes in thinking and mood but symptoms are insufficient to meet the diagnostic criteria for schizophrenia. The acute phase is when symptoms vary from mild to severe and become disabling. During this phase, the patient experiences delusions, hallucinations, withdrawn behaviors, and other functional impairment. The maintenance (or residual) phase is when the condition has stabilized and a new baseline is established. p. 196

Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years and Tara at 31 years. Based on knowledge of early- and late-onset schizophrenia, which statement is true? Aaron will be more likely to hold a job and live a productive life. Tara has a better chance for positive outcomes because of later onset. Tara and Aaron have the same expectation of a poor long-term prognosis. Tara will experience more positive signs of schizophrenia, such as hallucinations.

Tara has a better chance for positive outcomes because of later onset. Female patients diagnosed with schizophrenia between the ages of 25 and 35 have better outcomes than do their male counterparts diagnosed earlier. These two patients do not have the same expectation of a poor prognosis. There is no evidence suggesting that she will have more positive signs of schizophrenia. It is actually more unlikely that he will be able to live a productive life because of his earlier onset, which has a poorer prognosis. p. 193

The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill patient who has been diagnosed with schizophrenia is early detection of Acute dystonia Tardive dyskinesia Cholestatic jaundice Pseudoparkinsonism

Tardive dyskinesia An AIMS assessment should be performed periodically on patients who are being treated with antipsychotic medication known to cause tardive dyskinesia. p. 213, Figure 12.2

Which side effect of antipsychotic medication is generally nonreversible? Dystonic reaction Tardive dyskinesia Pseudoparkinsonism Anticholinergic effects

Tardive dyskinesia Tardive dyskinesia is not always reversible with discontinuation of the medication and has no proven cure. The side effects of anticholinergic effects, pseudoparkinsonism, and dystonic reaction often appear early in therapy and can be minimized with treatment. pp. 211, 213, 215, Table 12.6

A nursing intervention designed to help a patient with schizophrenia manage relapse is to Schedule the patient to attend group therapy that includes those who have relapsed Teach the patient and family about behaviors associated with relapse Remind the patient of the need to return for periodic blood draws to minimize the risk for relapse Help the patient and family adapt to the stigma of chronic mental illness and periodic relapses

Teach the patient and family about behaviors associated with relapse By knowing what behaviors signal impending relapse, interventions can be invoked quickly when the behaviors occur. The earlier the intervention, the greater the likelihood that a recurrence can be averted. p. 202, Box 12.2

A patient who recently loss a parent begins crying during a one-to-one session with the nurse. Which of the following responses by the nurse illustrates empathy? "I'm so sorry. My father died 2 years ago, so I know how you are feeling." "You need to focus on yourself right now. You deserve to take time just for you." "That must have been such a hard situation for you to deal with." "I know that you will get over this. It just takes time."

That must have been such a hard situation for you to deal with." This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient she will get over it does not reflect empathy and is closed-ended.DIF: Cognitive Level: Analyze (Analysis)REF: pages 22, 23TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

A patient with schizophrenia says, "I could hear the dog barking. It is trying to bite me." The nurse has taught hallucination-coping techniques to the patient's family to facilitate the patient's rehabilitation at home. What would be the most appropriate action by the patient's family in this case? SELECT ALL APPLY The family members should ask the patient to read loudly. The family members would ask the patient to clean the house. The family members should ask the patient not to go anywhere. The family members should ask the patient to cover his or her ears. The family members should ask the patient to close his or her eyes.

The family members should ask the patient to read loudly. The family members would ask the patient to clean the house. It is helpful if family members are included in the treatment of a patient with schizophrenia. They form a support group for the patient and thus are taught different coping techniques for hallucinations and delusions. It is useful to use other auditory stimuli to overcome auditory hallucination in patients with schizophrenia. The patient should be asked to read loudly or listen to music in such cases. The patient may also be engaged in an activity like cleaning the house. Asking the patient to cover the ears will not help the patient to overcome auditory hallucinations. The patient should be taken to a favorite place so he or she can relax. Asking the patient to close his or her eyes will not help the patient to overcome hallucinations. pp. 208-210

A nurse plans a series of psychoeducational groups for persons with schizophrenia. Which topic would take priority? How to give and receive compliments The importance of taking medication correctly How to complete an application for employment Ways to dress and behave when attending community events

The importance of taking medication correctly Although completing applications, dressing and behaving correctly, and giving and receiving compliments are important, correct self-management of pharmacotherapy takes priority. The patient cannot maintain remission without the appropriate medication. p. 202, Box 12.2

The preferred seating arrangement for a nurse-client interview should incorporate which positioning? The nurse behind a desk and the client in a chair in front of the desk. The nurse and client sitting at a 90-degree angle to each other. The client sitting in a chair and the nurse standing a few feet away. The nurse and client sitting facing each other.

The nurse and client sitting at a 90-degree angle to each other. This arrangement allows the nurse to observe the client but places no barriers between the principals. The two are at the same height, so neither is in an inferior position. Face-to-face seating is a more confrontational arrangement and therefore more anxiety producing.REF: 150

A patient is prescribed intramuscular fluphenazine. On the 15th day, the nurse finds the patient is stiff, dripping saliva, and has a masklike face. What is the most appropriate action by a nurse to help the patient? The nurse should administer the drug orally. The nurse should administer chlorpromazine. The nurse should administer trihexyphenidyl. The nurse should consult the health care provider. The nurse should provide the patient with a handkerchief.

The nurse should administer trihexyphenidyl. The nurse should consult the health care provider. The nurse should provide the patient with a handkerchief. Fluphenazine is a high-potency antipsychotic drug. It may cause pseudo-Parkinsonism between 5 and 30 hours after administering. The nurse should consult the primary health care provider to report the adverse effects and to change the drug. The nurse should administer the anticholinergic drug trihexyphenidyl to reduce the symptoms. The nurse should provide a handkerchief to wipe the saliva. A nurse cannot change the drug and administer chlorpromazine without the consent of the primary health care provider. The nurse should not change the dosage because it may cause adverse effects. p. 215, Table 12.6

What is the focus during clinical supervision? The nurse's behavior in the nurse-client relationship Analysis of the client's motivation for transferences Devising alternative strategies for client growth Assisting the client to develop increased independence

The nurse's behavior in the nurse-client relationship Clinical supervision helps the nurse look at his or her own behavior and determine more effective approaches to working with clients. None of the other options are associated with clinical supervision.REF: 151

A nurse is educating a patient's family about schizophrenia. What is the most appropriate advice the nurse can give to the patient's family? The nurse should advise them to adhere to the treatment plan. The nurse should advise them to keep in touch with support groups. The nurse should advise them to keep the patient in an isolated room. The nurse should avoid mentioning the side effects of the drugs prescribed. The nurse should advise them to immediately stop the medication if the patient's symptoms are relieved.

The nurse should advise them to adhere to the treatment plan. The nurse should advise them to keep in touch with support groups. The nurse should advise the family of the patient to join support groups such as National Alliance on Mental Illness and other local support groups. These groups would help to provide optimal patient care as well as support to the family. Adherence to the treatment plan would result in positive outcomes for the patient. The patient's family must be educated about the possible side effects of the prescribed drugs. This would help in effective monitoring and reducing panic in the patient and family members. The patient should be encouraged to interact with others. Keeping the patient isolated can make the patient either aggressive or withdrawn. The medications should not be stopped immediately after the symptoms are relieved because it could cause relapse of the schizophrenic symptoms. Gradually decreasing the dosage of the drug would be useful to prevent a relapse. p. 210, Box 12.5

A patient with schizophrenia prescribed with trihexyphenidyl complains of constipation. What is the most appropriate action by a nurse to help the patient? The nurse should give prune juice. The nurse should prescribe benztropine. The nurse should discontinue administration of the drug. The nurse should report to the primary health care provider.

The nurse should give prune juice. Constipation is a side effect usually caused by anticholinergic drugs like trihexyphenidyl. A nurse can help by advising the patient to take fluids like prune juice and water, as well as eat fiber-rich foods. A nurse should not discontinue administration of the medication because patients with schizophrenia develop extrapyramidal side effects (EPSs) as a result of conventional antipsychotics. Trihexyphenidyl is a centrally acting anticholinergic that reduces EPS. A nurse should report to the primary health care provider, but it is not the primary action to be taken. Benztropine is an anticholinergic drug. It has the same side effects as that of trihexyphenidyl. p. 215, Table 12.6

A patient with schizophrenia often becomes aggressive and bangs his head on the wall. What is the most appropriate action toward the patient by the nurse? The nurse should seclude the patient. The nurse should leave the patient alone. The nurse should make frequent visits to the patient. The nurse should shout when the patient is aggressive. The nurse should find out the reason for the patient's aggressiveness.

The nurse should seclude the patient. The nurse should make frequent visits to the patient. The nurse should find out the reason for the patient's aggressiveness. Patients with schizophrenia become aggressive during the acute phase and may try to harm themselves as a result of hallucinations. A nurse should seclude such patients to avoid the risk of patients harming themselves or others. A nurse should also try to determine the cause of the aggressive impulse and minimize or avoid it. Such patients must always be kept under continuous supervision. Therefore, it is also appropriate that the nurse frequently visits the patient. Shouting at the patient may cause the patient to withdraw or may make the patient more aggressive. Leaving the patient unattended can cause potential harm to the patient. p. 207, Table 12.3

A nurse observes multiple patients with schizophrenia in a ward. The patients do not like to interact with others and believe that the others would cause harm. What is the most appropriate action a nurse should take for such patients? The nurse should take the patients to the garden. The nurse should not give any task to the patients. The nurse should ask the patients about their family. The nurse should keep the patients away from peers.

The nurse should take the patients to the garden. The patients should be engaged in recreational activities and should be taken out to the garden. This helps to increase social comfort and leisure skills. Patients with schizophrenia should not be asked about the family frequently, because it may cause withdrawal. The patients should also be encouraged to mingle with peers and to interact with them. This promotes interaction skills in the patient. Patients should also be encouraged to participate in group activities. Patients should be involved in a task and encouraged to complete it. This enhances their self-esteem. p. 208

A patient with schizophrenia was prescribed antipsychotics. After daily observation, the nurse finds the patient's blood pressure has decreased. What is the most appropriate action by a nurse before administering the prescribed drug to the patient? The nurse should tell the patient to rise slowly. The nurse should tell the patient to avoid taking fluids. The nurse should avoid administering the drug for the day. The nurse should give an adrenergic agonist to raise the blood pressure.

The nurse should tell the patient to rise slowly. Antipsychotics block the α 2-receptor, which may cause hypotension. The nurse can give advice to the patient to rise slowly from the bed because the patient may feel dizzy as a result of reduced blood pressure. The nurse cannot administer the adrenergic agonist but can report to the health care provider if the patient's diastolic pressure falls below 80 mm Hg. The nurse should not stop administering the drug because that may worsen the schizophrenic symptoms. The nurse should not advise the patient to avoid fluid intake, because the patient may feel dehydrated and the total pressure exerted on the blood vessels maybe reduced. pp. 215-216, Table 12-6

When preparing to hold an admission interview with a client, the nurse pulls up a chair and sits facing the client with his or her knees almost touching. When the nurse leans in close to speak, the client becomes visibly flustered and gets up and leaves the room. What is the most likely explanation for client's behavior? The nurse violated the client's personal space by physically being too close. The client has issues with sharing personal information. The nurse failed to explain the purpose of the admission interview. The client is responding to the voices by ending the conversation.

The nurse violated the client's personal space by physically being too close. By sitting and leaning in so closely, the nurse has entered into intimate space (0 to 18 inches), rather than social distance. This has likely made the patient may feel uncomfortable with being so close to someone unknown to them. All the other options lack evidence and jump to conclusions regarding the patient's behavior.DIF: Cognitive Level: Analyze (Analysis)REF: page 34TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

A nurse is caring for a patient with schizophrenia. The nurse observes that the patient does opposite of any given instruction unintentionally and the patient often runs in the corridor. What is the probable diagnosis by the nurse from such behavior? The patient is restless. The patient has negativism. The patient has hearing problems. The patient does not like the nurse.

The patient has negativism. Schizophrenia is characterized by the symptoms of negativism, in which patients tend toward resistance and to do the opposite of what they are told. These patients also have motor agitation, in which they run or pace rapidly in response to stimuli and show unintended excessive movements. The patient's behavior is unlikely to be due to hearing problem, restlessness, or dislike toward the nurse.

A patient is on conventional antipsychotics. On clinical observation, the nurse finds that the patient has hyponatremia, increased confusion, and delirium. Which is the most likely cause of the patient's condition? The patient is dehydrated. The patient has stopped taking medication. The patient is not responding to the medication. The patient has potentially fatal water intoxication.

The patient has potentially fatal water intoxication. Antipsychotics are usually prescribed in combination with anticholinergics because they cause dry mouth. The patient feels excessive thirst and drinks lots of water. This results in water intoxication, which is indicated by hyponatremia, confusion, and worsening of the psychotic symptoms. If the patient has stopped taking medication or is not responding to them, it would lead the psychotic conditions to worsen as well. It would not produce hyponatremia. In addition, mental stress would not cause hyponatremia. Fatal water intoxication occurs as a result of excessive water intake. The signs do not indicate that the patient is dehydrated. p. 194

In a clinical interview conducted at a community health care center, the nurses observe that a patient with schizophrenia is very sensitive and feels extremely guilty about previous actions. What is the appropriate nursing diagnosis? The patient is a victim of child abuse. The patient has risk for self-directed violence. The patient has impaired verbal communication. The patient is showing positive symptoms of schizophrenia.

The patient has risk for self-directed violence. The patient with schizophrenia shows negative symptoms such as self-blaming, guilt, and becoming sensitive. It indicates that the patient is at risk for self-directed violence and can do self-harm. Impaired verbal communication is characterized by dissociative ideas. Positive symptoms of schizophrenia include hallucination and associative looseness. Feeling guilty and being sensitive are negative symptoms of schizophrenia. Schizophrenia is not associated with a history of child abuse. pp. 201, 207, Table 12.2, Table 12.3

A patient with schizophrenia was prescribed perphenazine. During the follow-up visit after 12 weeks on the medication, the nurse suggests that the patient go on bed rest and follow a diet rich in proteins and carbohydrates. Which is the most appropriate reason for the nurse to give this suggestion? The patient has the symptoms of agranulocytosis. The patient has the symptoms of cholestatic jaundice. The patient has the symptoms of postural hypotension. The patient has the symptoms of autonomic dysfunction.

The patient has the symptoms of cholestatic jaundice. Schizophrenic patients taking perphenazine, a first-generation antipsychotic drug, may have toxic effects as a result of long-term therapy. The nurse should identify the signs and symptoms of the toxic effects, like cholestatic jaundice, which is due to collection of bile juice in the gallbladder. The patient should be instructed to go on bed rest and consume a diet rich in proteins and carbohydrates. Postural hypotension is characterized by a drop in blood pressure with a change in position. It cannot be managed by a protein-rich diet. Agranulocytosis is characterized by dangerously low levels of white blood cells; this condition is not related to bed rest and diet changes. Autonomic nervous system controls involuntary actions of the body. An autonomic dysfunction is not treated by bed rest and diet changes. p. 212, Table 12.5

A nurse is caring for a patient with schizophrenia. Upon the nurse's report, the primary health care provider prescribed 25 mg of diphenhydramine hydrochloride to the patient. What had the nurse reported to the primary health care provider about the patient? The patient has a peptic ulcer and asthma. The patient has mydriasis and photosensitivity. The patient has tremors and tardive dyskinesia. The patient has excessively dry mucous membranes.

The patient has tremors and tardive dyskinesia. Patients with schizophrenia are generally prescribed antipsychotic drugs. These drugs cause extrapyramidal side effects, like tremors, and abnormal involuntary movements, like tardive dyskinesia. Diphenhydramine hydrochloride 25 mg by the intramuscular or intravenous route is prescribed to such patients to treat extrapyramidal side effects. Diphenhydramine hydrochloride is contraindicated in patients with peptic ulcer and asthma because it causes stomach distress like nausea, vomiting, and diarrhea. Physostigmine and benzodiazepines are administered to control these symptoms. Photosensitivity and mydriasis are symptoms of anticholinergic toxicity. Dry mucous membranes can be a symptom of anticholinergic toxicity but are not a major concern with the administration of diphenhydramine hydrochloride. p. 211

A nurse is devising a treatment plan for a patient who is in the first phase of schizophrenia. Which of these actions by the patient supports the assumption that the patient is in the first phase of schizophrenia? The patient takes the medication properly. The patient has good interactions with others. The patient hears the voice of a late grandfather. The patient repeats the words uttered by the nurse. The patient reports that the primary health care provider tried to kill him.

The patient hears the voice of a late grandfather. The patient repeats the words uttered by the nurse. The patient reports that the primary health care provider tried to kill him. Schizophrenia is characterized by three phases. The first phase is the acute phase. In this phase, the patient has positive schizophrenia symptoms such as hallucinations, echolalia, and paranoia. The patient may hear unusual voices and repeat what others have said. The patient also may have irrational fears and may believe that the primary health care provider had tried to kill him. In the second phase of schizophrenia, the patient starts taking medication and shows improvement. In this phase, the patient also develops an ability to interact with others. pp. 201-204

Which assessment finding supports the belief that the patient is demonstrating a positive symptom of schizophrenia? The patient states, "Nothing is fun anymore." The patient unable to decide on what foods to select for dinner. The patient finds it difficult to sit quietly, stating, "I have to fidget." The patient refuses to sleep because "I'll be abducted by the aliens." The patient is unable to remember his or her personal telephone number.

The patient refuses to sleep because "I'll be abducted by the aliens." The four main symptom groups of schizophrenia are (1) positive symptoms: the presence of something that is not normally present (e.g., hallucinations, delusions, bizarre behavior, paranoia, abnormal movements, gross errors in thinking); (2) negative symptoms: the absence of something that should be present (e.g., interest in hygiene, motivation, ability to experience pleasure); (3) cognitive symptoms: often subtle changes in memory, attention, or thinking (e.g., impaired executive functioning [the ability to set priorities or make decisions]); (4) and affective symptoms: symptoms involving emotions and their expression. pp. 197, 201, Table 12.2

A 55-year-old patient recently came to the United States from England on a work visa. The patient was admitted for severe depression following the death of a life partner weeks ago. While discussing the death and its effects the patient shows little emotion. Which of the following explanations is most plausible for this lack of emotion? The patient in denial. The response may reflect cultural norms. The response may reflect personal guilt. The patient may have an antisocial personality.

The response may reflect cultural norms. Showing little emotion while in distress may be a cultural phenomenon. Some cultures, such as the British and German cultures, tend to value highly the concept of self-control and may show little facial emotion in the presence of emotional turmoil. There is no evidence to suggest the patient's lack of emotion is a result of any of the other options.DIF: Cognitive Level: Analyze (Analysis)REF: page 9TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity

When a nurse and client meet informally or have an otherwise limited but helpful relationship, what term is used to identify this relationship? Crisis intervention Therapeutic encounter Autonomous interaction Preorientation phenomenon

Therapeutic encounter A therapeutic encounter is a short but helpful interaction between the nurse and client. None of the other options reflect this form of relationship.REF: 126-127

The client makes the decision to sit about 5 feet away from the nurse during the assessment interview. The nurse can accurately make what assumption about the client's perception of the nurse? The nurse is a safe person to interact with. The nurse is a new friend. They view the nurse as a stranger. They view the nurse as a peer.

They view the nurse as a stranger. Social distance (4-12 feet) is reserved for strangers or acquaintances. This is often the client's perception of staff during the initial phase of relationship-building. This behavior is not associated with any perception provided by any other option.REF: Page 151

A patient diagnosed with schizophrenia receives an injection of fluphenazine monthly. Which assessment findings indicate that this patient is experiencing extrapyramidal symptoms? Tremor Drooling Dry eyes Constipation Shuffling gait

Tremor Drooling Shuffling gait Fluphenazine is a first-generation antipsychotic medication. These medications commonly cause extrapyramidal symptoms, which include masklike faces, stiff and stooped posture, shuffling gait, drooling, tremor, "pill-rolling" movements, and akathisia. Constipation and dry eyes are anticholinergic side effects. pp. 211, 212, Table 12.4, Table 12-5

The nurse is caring for a patient with schizophrenia who was given an injectable dose of dopamine (D 2) antagonists for the limbic center. Which side effects does the nurse anticipate? Tremors Difficulty walking Increased energy Loosening of reflexes Pacing back and forth Muscular contraction in the neck

Tremors Difficulty walking Pacing back and forth Muscular contraction in the neck Dopamine antagonists are first-generation antipsychotics that are used less frequently because of their side effects. The medications block D 2 receptors, causing extrapyramidal side effects that include pacing and general restlessness (akathisia); muscular contractions (acute dystonia); gait impairment; and tremors (pseudoparkinsonism). These agents do not loosen reflexes or increase energy, though akathisia can sometimes be confused with increased energy.

Which drug would a nurse anticipate being given with chlorpromazine to reduce extrapyramidal side effects? Lamivudine Valacyclovir Montelukast Trihexyphenidyl

Trihexyphenidyl Chlorpromazine is a first-generation antipsychotic drug. It can cause extrapyramidal side effects, like akathisia, tremor, impaired gait, and so on, as a result of the blockage of dopamine receptors. These side effects can be treated by administering antiparkinson drugs like trihexyphenidyl. Trihexyphenidyl is an antimuscarinic class of drug. Montelukast is a leukotriene receptor antagonist used to treat asthma. Lamivudine is a nucleoside reverse transcriptase used to treat HIV/AIDS; it cannot be used to reduce the extrapyramidal side effects of chlorpromazine. Valacyclovir is an antiviral drug used to treat viral infections. p. 211

What therapeutic communication technique is the nurse using by asking a newly admitted patient, "Please tell me what was happening that led to your hospitalization here?" Using a minimal encourager Using an open-ended question Paraphrasing Reflecting

Using an open-ended question Open-ended questions require more than one-word answers. This question encourages the patient to provide a narrative concerning the circumstances surrounding the need for admission.REF: 143

A patient diagnosed with schizophrenia and experiencing command hallucinations had a brief stay on an inpatient unit. Afterward, the patient was transferred to a partial hospitalization program. Which outcome is most appropriate to achieve by the end of the first week of partial hospitalization? The patient will Express self clearly and in organized sentences Clearly describe the content and source of the hallucinations Ask the nurse for medication when experiencing hallucinations Verbalize an understanding that hallucinations are a sign of the illness

Verbalize an understanding that hallucinations are a sign of the illness Anosognosia refers to an inability to realize an illness exists. This problem occurs in many persons diagnosed with schizophrenia. If the patient recognizes that hallucinations are an aspect of the illness, he or she has made initial progress in management of the illness. It will take longer than 1 week for the patient to communicate clearly and in organized sentences. The patient does not know the source of hallucinations and it is not productive to explore their content in detail. The patient should take medication daily, not just when experiencing hallucinations. pp. 200, 206, Table 12.3

A patient diagnosed with schizophrenia has been drinking frequently from the water fountain and taking drinks from peers' meal trays. The staff has observed an increase in auditory hallucinations and episodes of acute confusion. Which nursing actions are appropriate? SELECT ALL THE APPLY Weigh the patient daily. Restrict the patient's access to fluids. Assess the patient for water intoxication. Administer an as needed dose of the patient's antipsychotic medication. Monitor the patient daily to identify any changes in mental status.

Weigh the patient daily. Restrict the patient's access to fluids. Assess the patient for water intoxication. Polydipsia can lead to fatal water intoxication (indicated by hyponatremia, confusion, worsening psychotic symptoms, and, ultimately, coma). Polydipsia occurs in upwards of 20% of persons with schizophrenia and a seemingly insatiable thirst can cause hyponatremia in 2% to 5%. Contributing factors include antipsychotic medication (causes dry mouth), compulsive behavior, and neuroendocrine abnormalities. Additional medication is not indicated at this time; physiological needs have a higher priority. This patient needs very frequent observation for changes in status; every 15 minutes or continuous observation will better provide for the patient's safety. p. 194

A patient with undifferentiated schizophrenia lives in a community care home and takes olanzapine daily with supervision. During the patient's monthly outpatient visits with a psychiatric nurse, which assessment parameter takes priority? Height Weight Pupillary response to light Integrity of mucous membranes

Weight An important part of the nurse's role in the community is monitoring the patient's response to medications, compliance, and potential side or adverse effects. Key side effects of sexual dysfunction and weight gain are particularly important to monitor for persons taking antipsychotic medications. Olanzapine is an atypical antipsychotic drug that can cause significant weight gain, which results in diabetes for many patients. Neither height, mucous membrane integrity, nor pupil response takes priority over weight. p. 202, Box 12.2

A community mental health nurse cares for a patient diagnosed with schizophrenia who takes olanzapine. In addition to monitoring the patient's mental status, the nurse regularly should assess what of the patient? Height Weight Blood glucose Blood pressure Peripheral pulses

Weight Blood glucose Blood pressure Peripheral pulses Olanzapine is a second-generation antipsychotic medication. These medications have a high risk of causing metabolic syndrome. It is important to monitor blood glucose, weight, and serum lipids, as well as indicators of diabetes, atherosclerotic heart disease, and hypertension. Height is not relevant. p. 212, Table 12-5,p. 211, Table 12.4

Which of the following symptoms would alert a health care provider to a possible diagnosis of schizophrenia in a young adult patient? Excessive sleeping with disturbing dreams Command hallucinations to hurt roommate Withdrawal from college because of failing grades Chaotic and dysfunctional relationships with family and peers

Withdrawal from college because of failing grades People diagnosed with schizophrenia all have at least one psychotic symptom, such as hallucinations, delusional thinking, or disorganized speech. Excessive sleeping, failing grades, and chaotic and dysfunctional relationships do not describe schizophrenia but could be caused by a number of problems. p. 192

A client has been admitted to your inpatient psychiatric unit with suicidal ideation. In a one-to-one session with the nurse, he shares the terrible guilt he feels over sexually abusing his stepdaughter and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship? "It's good that you feel guilty. That means you still have a chance of being helped." "Of course you feel guilty. You did a horrendous thing. You shouldn't even forget what you did." "The biggest question is, will you do it again? You will end up having even worse guilt feelings because you hurt someone again." "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."

You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living." This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship.DIF: Cognitive Level: Analyze (Analysis)REF: pages 25 TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity

A client states "That nurse never seems comfortable being with me." The nurse can be described as not seeming genuine to the client. transmitting fear of clients. unfriendly and aloof. controlling.

not seeming genuine to the client. Hiding behind a role, using stiff or formal interactions, and creating distance between self and client suggest a nurse is lacking in genuineness, or the ability to interact in a person-to-person fashion. This characteristic is not associated with the other options.REF: 126-127, 133

the client who had a hysterectomy six months ago suddenly develops an intense fear of elevators. which the client approaches the building elevator, the client becomes panicky and cannot get on. the nurse knows that this client's fear of elevators is caused by which occurrence? 1. a projection of anxiety onto a neutral object 2. a common postop phenomenon in females 3. an attempt to undo her traumatic hospital experience 4. a conversion reaction to emotional stress

1. a projection of anxiety onto a neutral object the client has developed a phobia in which anxiety is projected onto a neutral object, the avoidance behavior symbolizes her anxiety

The client is told by the health care provider that the clients cancer is inoperable. the nurse enters the room for a short time later and finds the client crying. which action should the nurse take first? 1. acknowledge this is a sad time 2. quietly leave the room 3. call the chaplain or spiritual leader at the hospital 4. stress what can be done in the time remaining

1. acknowledge this is a sad time demonstrates the nurse's understanding and acceptance of grieving

which of the following signs and symptoms would the nurse observe in a patient who has recently taken heroin? 1. constricted pupils depressed respirations 2. dilated pupils increased respirations 3. vomitting and hypotension 4. agitation and tachycardia

1. constricted pupils and decreased respirations CNS depressed effects of constricted pupils and slow shallow breathing, drowsiness, slurred speech, and initial euphoria followed by dysphoria

the health care provider prescribes lithium carbonate for a client. the nurse understands that which medication is contraindicated for this client? 1. diuretics 2. MAOI 3. tricyclic antidepressants 4. antibiotics

1. diuretics lithium causes sodium depletion, diuretics are contraindicated for clients on lithium

The nurse admits the client with a diagnosis of schizophrenia to the unit. the client's needs are best met by which action? 1. give the client a brief orientation and stay with the client for a while 2. offer the client a description of ward activities and introduce the client to other clients 3. introduce the client to another client and ask the other client to give a short unit tour 4. sit with the client in a quiet room and wait until the hallucination stops

1. give the client a brief orientation and stay with the client for a while since the client has a reduced attention span and an inability to concentrate a brief orientation is best by staying with the client the nurse conveys an attitude of caring and protection

The nurse cares for a client diagnosed with antisocial personality disorder. which of the following statements if made by the patient to the nurse best indicates improvement in the patents condition? 1. i get into trouble because i don't think before i act 2. my parents have difficulty accepting my independence 3. I've spent very little time actually enjoying life 4. its sad that others don't recognize my potential

1. i get into trouble because i don't think before i act introspective remark shows that the patient is beginning to realize that she acts out of anxiety or tension without realizing the consequences of the actions

The home care nurse makes an initial visit for a client diagnosed with a myocardial infarction. the clients spouse states that she is having difficulty coping with the clients OC tendencies. which of the following statements made by the client to the nurse is consistent with OCD? 1. i have difficulty making decision and adjusting to change 2. i am sure I'm being followed by someone from work 3. all of my life I've had problems being unkempt 4. i spend money excessively which upsets my wife

1. i have difficulty making decision and adjusting to change clients with OCD have an extreme need to control and predict outcomes, making decisions and changes causes anxiety for these clients

when caring for a person with diagnosed a peptic ulcer, which of the following nursing measures is indicated? 1. identify the stress factors in the person's environment 2. avoid giving the person choices to make 3. encourage the person to become angry 4. avoid discussing the person's symptoms

1. identify stress factors in the person's environment important to identify elements in the patients environment that are contributing to stress when caring for a patient with a psychophysiological disorder

the nurse cares for a client diagnosed with a terminal illness it is most important for the nurse to take which action? 1. let the client know the client is not alone 2. attempt to promote hope in the client 3. be helpful to the client at all times 4. discourage denial in the client

1. let the client know the client is not alone very important in the care of a dying client, fear of the unknown is frightening

a terminal patient dies quietly in his sleep. the nurse should take which of the following actions? 1. provide a private place for family members 2. explain that the patient is in heaven now 3. notify the family members individually 4. shield the family from viewing the patient

1. provide a private place for family members shows compassion and understanding by the nurse

The nurse understands that in a psych inpatient setting, milieu therapy is best understood as 1. providing a therapeutic physical and social environment 2. manipulation of the envorionent in a way that makes the patient feel at home 3. establishing therapeutic communication with numerous staff members 4. setting limits on behavior

1. providing a therapeutic physical and social environment social, cultural, and physical environment are used as instruments of growth to the patient's benefit

The nurse observes that a client develops a strong attachment to another patient who repeatedly insults him. the nurse understands that this is an example of which of the following? 1. reaction formation 2. undoing 3. displacement 4. introjection

1. reaction formation expressing an attitude that is directly opposite to an unconscious wish or fear

The 29 year old woman told by the healthcare provider that she cannot have children subsequently forms a close attachment to her niece and nephew. the nurse understands this is an example of which defense mechanism? 1. sublimination 2. projection 3. undoing 4. rationalization

1. sublimination sublimation allows her to satisfy some of her unmet maternal instincts

The client diagnosed with paranoid schizophrenia tells the nurse, " i have a feeling of numbness in my legs. they feel like they don't belong to me, and I think someone on TV is controlling my walking." Which response by the nurse is best? 1. That must be an unpleasant experience for you. have you had these feelings before? 2. i know you are frightened now but soon the medication will ease your symptoms 3. part of your sickness is an imaginary world, in reality tv does not control people 4. tell me more about these feelings

1. that must be an unpleasant experience for you have you had these feelings before? the nurse acknowledges the client is feeling uncomfortable and attempts to have the client explain more about what is being felt; notice however the nurse does not discuss the delusional content but tries focusing on the feeling

the adolescent is admitted to the psych hospital the adolescent reports during the previous weekend the adolescent hit a sibling during an argument. after the argument the clients arm became paralyzed. the nurse anticipates that client will react in which way about the paralysis? 1. the client appears calm about the paralysis 2. the client expresses anxiety about permanent damage 3. the client improves with passive arm exercises 4. the client recognizes the symptoms aren't real

1. the client appears calm about the paralysis clients with conversion reactions usually appear calm and unconcerned with the physical manifestations, the anxiety is represses and is converted into a physical symptom

The nurse assists a terminally ill elderly patient with a morning bath routine. the patient says to the nurse, "why do you bother with me?' which response by the nurse is best? 1. would you prefer to be alone right now? 2. i care about you and how you are doing 3. i understand how you feel 4. this is a difficult disease isn't it

2. I care about you and how you are doing patient may feel guilty about being a burden, nurse helps the patient feel that she is not a lone and that she is valued and cared for

The nurse prepares a patient for surgery to remove a malignant tumor from the large intestine. The patient appears calm and relaxed and remarks to the nurse "my health is fine my physician is a pessimist" the nurse identifies that this statement is an example of 1. sublimination 2. denial 3. displacement 4. intellecutalization

2. denial denying the extent of his illness; denial protects him at this time from overwhelming anxiety

The client is placed on escitalopram 10 mg daily which side effect should the nurse instruct the patient to observe for? 1. photophobia 2. dizziness 3. epistaxis 4. hypertensive crisis

2. dizziness is a SSRI used to treat depression and OCD, side effects include insomnia, dizziness, diarrhea, nausea, sexual dysfunction, lack of sex drive, monitor for suicidal tendencies, administer in morning or evening with regard to food

a young man is brought to the ER by a friend the patient is agitated and screaming I can't stop seeing things. help me, i'm going crazy. his friend reports to the nurse that he too some LSD earlier in the day. It is MOST important for the ruse to take which of the following actions? 1. give the patient reflective feedback 2. stay with the patient and quietly attempt to talk to the patient down 3. set limits on the patients behaviors 4. place patient in a well lighted room close to the nurse's station

2. stay with the patient and quietly attempt to talk the patient down patients who have taken LSD frequently panic in response to sensory perceptual changes, reassure him that his response to LSD will pass

The woman is admitted to the hospital for a possible mastectomy. on the evening before his wife's scheduled surgery, the husband appears tense and paces up and down the hall. which comment by the nurse to the husband is best? 1. we will do everything we can to help your wife 2. this is an upsetting experience for you and your wife 3. you will feel relieved once the surgery is over 4. i think it might help you if we discussed your wife's surgery

2. this is an upsetting experience for you and your wife good broad opening, comments on the husbands nonverbal behavior and invites him to explore matters with the nurse

the nurse cares for clients in the mental health clinic. the client with depression joins an ongoing therapy group. what is the goal of the group therapy? 1. to introduce the client to other clients 2. to communicate acceptance to the client 3. to encourage decision making 4. to increase the clients sense of responsibility

2. to communicate acceptance to the client this is the most important thing to communicate initially, acceptance by others paves the way for self acceptance

The nurse prepares to lead a group lesson for clients with a dependent on alcohol. the nurse knows that an alcoholic client drinks because of which reason? 1. enjoys the feeling of being intoxicated 2. uses alcohol to escape from problems 3. has a greater alcohol tolerance than most people 4. performs more efficiently when drinking

2. uses alcohol to escape from problems use alcohol to escape from problems and is a way to decrease anxiety and tension

The nurse plans care for the client with a history of substance abuse. It is most important for the nurse to select which approach? 1. a structured but permissive setting 2. an environment that increases reality testing 3. a structured non permissive setting 4. an environment that decreases stimuli and redirects behavior

3. a structured non permissive setting it must be non permissive setting because permissive might foster manipulative behavior

The spouse of a phobic patient is troubled by his wives sudden fear of cars. He asks the nurse what should i do when she gets frightened. The nurse should urge the husband to? 1. ride with his wife in a car 2. encourage his wife to go for a ride in a car 3. allow his wife to avoid cars 4. encourage his wife to discuss her fears

3. allow his wife to avoid cars well meaning friends and family encourage a patient to encounter a feared object, this only increases apprehension and anger on the part of the patient

When intervening with a violent client, the nurse should take which action? 1. tell the client that they have no control over their behavior 2. point out that the client is making others anxious 3. identify the nurse to client and remain calm 4. touch the client gently to offer reassurance

3. identify the nurse to client and remain calm by identifying him/herself the nurse establishes a sense of authority and trust, in remaining calm, the nurse helps the client to feel less frightened and panicked

The nurse cares for the client with depression who attempts suicide. the nurse understands which is the most likely reason that the client attempts suicide? 1. the client is suspicious and mistrustful 2. the client consciously wishes to manipulate others 3. the client feels overwhelmed and helpless 4. the client wants to gain attention

3. the client feels overwhelmed and helpless the person loses hope and may turn to thoughts of suicide and suicide seems to be the only solution

The client appears angry and demanding following a below the knee amputation. which interpretation by the nurse of this clients behavior is most justifiable? 1. the client is seeking attention to compensate for the loss 2. the client is placing the blame for difficulties on others 3. the client is having difficulty accepting the new body image 4. the client feels alienated by the hospital staff

3. the client is having difficulty accepting the new body image is a common problem after loss of a body part

A client in the hypertension clinic expresses worry to the nurse that his wife has been unemployed for more than 6 months and that he is afraid that soon they will be unable to pay rent. which of these responses by the nurse is most important? 1. these things always seem worse than they really are 2. it is important for your blood pressure that you not worry too much about that 3. you're worried that you son't be able to pay the rent 4. i will refer you to a social worker

3. you're worried that you won't be able to pay the rent reflects feelings back to the client; allows the client to focus on what he said and what his feelings are

A patient is slumped on the floor with a razor blade in hand, blood pours from the wrist. a nurse finds the patient. what is most important for the nurse to do? 1. find out why the patient tried to commit suicide 2. telephone the doctor to explain the situation 3. ask a nurse assistant to hold his wrist while the nurse calls the doctor 4. call another nurse for help, stay with the patient

4. call another nurse for help, stay with the patient best response- should not leave the patient alone, nurses responsibility to stay

Chlordiazepoxide 10 mg PO bid is prescribed for a patient. the nurse should assess the patient for which of the following? 1. skeletal muscle spasms and insomnia 2. anorexia and dry mouth 3. diarrhea and euphoria 4. drowsiness and confusion

4. drowsiness and confusion causes CNS depressant effects of drowsiness and sedation; caution should be used when driving or operating equipment

The nurse cares for a patient diagnosed with depression and encourages the patient to join an activity. which of the following approaches by the nurse is best? 1. offer several appealing choices to the patient 2. tell the patient it is part of the physician's orders 3. describe the activity in detail to the patient 4. invite the patient to join in

4. invite the patient to join in its a good way to lead a patient into an activity, its important to demonstrate caring and acceptance

A graduate nurse fails an examination and accuses the psychiatric instructor of being an unfit teacher and causing the failure. the nurse identifies this as an example of 1. conversion 2. acting out 3. compensation 4. projection

4. projection unable to accept her sense of failure and resulting poor self-esteem, the student projects the failure onto the instructor thereby saving face but coping ineffectively

The nurse cares for a client diagnosed with conversion reaction. The nurse identifies that this client utilizes which defense mechanism? 1. introjection and denial 2. projection and displacement 3. identification and rationalization 4. repression and symbolization

4. repression and symbolization instinctive drives and their accompanying anxiety are repressed by the client with conversation reaction and converted into a physical symptom that has meaning

A patient diagnosed with bipolar depression is hospitalized in the elation phase of the illness. the patient says to the nurse, "i just bought myself a home computer and a large screen tv for the family. which of these interpretations by the nurse is most accurate? 1. the patient wants to impress the nurse with his generosity toward the family 2. the patient is insecure about his self worth and needs to manipulate electronic devices 3. the patient has completely lost contact with reality and his thought patterns are disturbed 4. the patient has a mood disturbance and his judgments poor at this time

4. the patient has a mood disturbance and his judgment is poor at this time people in a manic state may have delusions or grandeur and/or an exalted opinion of himself and his abilities

One day the parent of the client diagnosed with antisocial personality disorder says to the nurse "my child seems much better. i feel my child will finally grow up and assume responsibility." The nurse anticipates which prognosis is probable for this client? 1. the prognosis is good because there is no evidence of psychotic behavior 2. the prognosis is doubtful because psychotherapy will cause regression 3. the prognosis is good because with medication and psychotherapy, the problem will be resolved 4. the prognosis is doubtful because only some antisocial clients change their behavior

4. the prognosis is doubtful because only some antisocial clients change their behavior antisocial clients have little motivation for change, usually move from situation to situation in an opportunistic fashion

One morning the nurse finds the client crying and approaches. The client says, "what do you want? go away, you can't help me. I hate you and I hate myself." Which response by the nurse is best? 1. why is that you dislike means yourself 2. ill come back later when you feel in a better mood 3. its difficult for me to communicate with you when you talk this way 4. you seem to be in pain, ill stay with you for a while

4. you seem to be in pain ill stay with you for a while conveys support and understanding

Kaplan Psychiatric Nursing 1 The nurse provides care for clients in the pediatric clinic. The nurse understands that according to Erikson's stages of psychosocial development, trust and significant early attachments develop during which time period? a. Birth-18 months b. 18 months-3 years c. 3-6 years d. 6-12 years

a. CORRECT - From birth to 18 months, the child learns what is predictable and dependeable about the environment and the primary caretaker as these are the basic elements of trust. If all goes well at this time, the attachment between parents and child is strong and the child can move on to exploring and manipulating the environment. b. The toddler works to achieve autonomy, learn self-control, and how to manipulate the environment. c. The preschooler works on initiative, learns assertiveness and purpose to influence the environment. Work begins to evaluate own behavior during this stage of development. d. The school age child works to master industry and develops a sense of completeness.

Kaplan Psychiatric Nursing 1 The nurse instructs the client about phenelzine sulfate. Which client statement indicates to the nurse that further teaching is necessary? a. "I can't wait to eat a hot dog with sauerkraut." b. "I'm going to have to get some polycarbophil when I get home." c. "I will be playing doubles tennis with my neighbors." d. "When I get home, I am going to take my car out for a road trip."

a. CORRECT - monoamine oxidase inhibitor; client should avoid foods such as aged cheese, beer, red wine, dry sausage, sauerkraut, liver because they are high in tyramine; may precipitate a hypertensive crisis b. polycarbophil is a bulk forming laxative used to treat constipation; phenelzine does not cause constipation. c. activity is okay; phenelzine may cause orthostatic hypotension; encourage client to get out of bed slowly; sit at bedside before walking d. no restriction

Kaplan Psychiatric Nursing 1 The parent of two school-age children tells the nurse that the spouse has recently become unemployed and the client reports feeling depressed. The nurse understands which statement to be true? a. The spouse's unemployment is a significant potential stressor. b. The spouse's unemployment is irrelevant. c. Unemployment is mainly a factor in development crises. d. The client is using the spouse's unemployment to avoid their own problems.

a. CORRECT - stress occurs when a client is unable to cope with external or internal demands; the source of the stress is called a stressor; stressors include injury, illness, death, changes in employment or finances, changes in relationship, childbearing; socioeconomic factors can be major supports as well as important potential stressors; clients under financial pressure may secretly break down under the stress b. client's concern about changes in life can affect the depression c. developmental crisis are predictable life events that occur during one's life (courtship and marriage, children; unemployment is a situation crises; other examples of situation crises include death, job change, moving, illness d. change in job status and financial security are stressors

Kaplan Psychiatric Nursing 1 The mother of two delivers a newborn with a cleft palate. The parents visit the baby in the newborn nursery. Which statement by the nurse to the parents is BEST? a. "Sit in that rocking chair so that you can hold your baby." b. "We feed the infants every four hours." c. "I'll hold your baby while you look at him." d. "You can watch the nurse give your baby a bath."

a. CORRECT - these parents are experiencing grief because they have a child with a serious defect; the nurse should promote the parents' participation in the child's care, which will ease their anxiety and sense of helplessness; encouraging the parents to touch and hold the child is a good way to promote family cohesion b. important to give the parents information, but it is most important to encourage family to hold and care for infant c. encourage parents to care for infant d. encourage parents to care for infant

Kaplan Psychiatric Nursing 1 The client comes to the local clinic reporting dizziness and a "racing heart". The client's physical exam is normal. The client reports that the client's company recently lost a large sum of money, and the client feels resposible. The client tells the nurse that the client is extrememly anxious. Which response by the nurse is BEST? a. "When did you first notice that you were feeling anxious?" b. "Have you shared this information with a loved one?" c. "Are you worried about having to visit the health care provider?" d. "Would you like to discuss it with me?"

a. CORRECT - this question is therapeutic communication; helping the client to identify precipitating causes is an important second step once the client is able to acknowledge anxiety b. seeking information by asking a yes-no question; closed-ended question prevents client from sharing feelings c. seeking information by asking a yes-no question; closed-ended question prevents client from sharing feelings; assumes that is worried about the health care provider d. seeking information by asking a yes-no question; closed-ended question prevents client from sharing feelings

Kaplan Psychiatric Nursing 1 The nurse cares for clients in the pediatric clinic. The parent of the younger child asks the nurse why the child is involved in play therapy. Which statement by the nurse is BEST? a. "Young children have difficulty verbalizing emotions." b. "Children hesitate to confide in anyone but their parents." c. "Play is an enjoyable form of therapy for children." d. "Play therapy is helpful in preventing regression."

a. CORRECT - young children are not able to conceptualize their feelings and put them into words; play is how they express themselves; play therapy is the most effective way for the nurse to enter the child's word b. play therapy enables the child to express him/herself c. play allows the child to release excessive energy, master situations, resolve conflicts, and relieve anxiety; play is essential to a child's growth and development d. allows children to express thoughts and feeling

Kaplan Psychiatric Nursing 1 The nurse anticipates which group of symptoms when caring for a client with disorientation due to dementia? a. Judgment alterations, memory deficit, irritability b. Anorexia and weight loss, fatigue, hopelessness c. Confusion, delirium, hallucinations d. Impaired motor skills, lack of coordination, mood changes

a. CORRECT- characteristic symptoms of organic brain syndrome are judgment alterations, memory deficits, and irritability b. describes depression c. describes delirium; rapid onset; secondary to physical illness, medication, dehydration; interventions determined by underlying cause d. may indicate CVA

Kaplan Psychiatric Nursing 1 The nurse overhears the client diagnosed with dementia tell a story about something that the nurse knows is not true. Which action by the nurse is BEST? a. Correct the information as presented. b. Allow the client to continue the story. c. Refer the client for reminiscence therapy. d. Orient the client to person, place, and time.

a. do not challenge the client b. CORRECT - supports a positive self-image; confabulation serves as a defense against memory impairment; avoiding confrontation over fabricated stories will alleviate factors affecting dementia, and avoid increasing demands on the client's coping mechanisms c. elderly clients recall past events and feelings; assist reality orientation d. dose not indicate that client is disoriented

Kaplan Psychiatric Nursing 1 The nurse knows that, according to Maslow's hierarchy of needs, which needs are MOST basic to any client's health maintenance plan? a. Love and belonging b. Esteem and recognition c. Safety and security d. Self-actualization

a. Maslow's hierarchy of needs states that some needs are more basic than others, and the basic needs have to be met first; the most basic needs are the physiological needs (oxygen, food, water, etc); if the basic needs are not met, the person will die; working on love and belonging occurs after the basic needs are met as well as the need for safety and security b. person has positive self-esteem and the recognition of others; this level occurs after mastering love and belonging c. CORRECT - the person establishes stability and consistency in life; is mostly psychological; if person dose not feel safe, there is no energy for the other pursuits d. highest level; person becomes everything that s/he is capable of becoming

Kaplan Psychiatric Nursing 1 The nurse cares for clients in an inpatient psychiatric unit and leads an adolescent social/support group to discuss the difficulties of growing up in today's society. The nurse knows that the therapeutic benefit of this group is based on which concept? a. The group's ability to evaluate their behavior. b. The phase of the group's interaction. c. The leader's skill in promoting progress. d. The group member's sense of belonging.

a. age-related groups focused on issues that are specific to their developmental age; may be supportive or educational b. stages of group development include: pre-group stage (selecting group members, determining when, where, and how often to meet, etc); initial stage (norms are established, rank and status of group members emerges); working stage (focus on accomplishing established goals); final stage (termination of group; what will happen when group is over) c. group leader initiates the group, provides continuity, and facilitates cohesiveness d. CORRECT - teenagers are strongly influenced by their peers; the therapeutic benefit of this group can be enhanced through a sense of belonging in which they can establish norms for behavior and work through shared problems

Kaplan Psychiatric Nursing 1 The client is brought to the emergency department by family members after taking an overdose of diazepam. The family reports the client has become increasingly depressed and withdrawn during the previous month. Which question is MOST important for the nurse ask during the initial interview? a. "Why did you do this to yourself?" b. "Can you elaborate on what is bothering you?" c. "Exactly what, how much, and when did you take the medication?" d. "Did you seriously think of killing yourself?"

a. avoid judgmental remarks or interpretations b. yes-no question, which is nontherapeutic; client s physical condition takes priority c. CORRECT - most important first step in assessing this client is to establish exactly what substances were taken, how much, and when; nurse can then decide what emergency interventions are necessary d. if client threatening suicide, ask about plans; not appropriate in this situation; more important to attend to client's physical needs

Kaplan Psychiatric Nursing 1 The client diagnosed with inoperable cancer has difficulty walking after chemotherapy. When the nurse comes to assist the client to the bathroom, the client says, "Leave me alone. You treat me like a child." Which interpretation of the client's behavior, by the nurse, is MOST justifiable? a. The client is frightened about falling. b. The client is entering a regressive phase. c. The client want to maintain independence. d. The client is angry at the nurse's interference.

a. client is frightened about losing independence b. is projecting fear and anger c. CORRECT - clients are often frightened by dependence and have difficulty expressing their fear and anger to caretakers; they use projection and displacement to maintain a level of denial until they are ready to move toward acceptance. d. is projecting feelings

Kaplan Psychiatric Nursing 1 The client with a diagnosis of antisocial personality disorder fails to arrive on time for a scheduled appointment with the nurse. The nurse contacts the client to remind the client of the appointment, and the client states, "I would rather meet between 12 and 1." Which response by the nurse is BEST? a. "Perhaps we can make that change the next time." b. "Is there something you are having trouble discussing?" c. "I would have to discuss any changes with the team first." d. "Are you having some difficulty with the time you agreed to?"

a. clients with personality disorder have presenting problems that represent dysfunctional behavior patterns (have a disregard for the rights of others, display lack of guilt, remorse, and conscience); because a client with antisocial personality is impulsive and duplicitous, it's important the nurse set firm limits; offering to change the time of the appointment is as example of inconsistency b. nontherapeutic, ye-no question; nurse must confront behaviors consistently and enforce consequences c. nurse needs to deal with situation d. CORRECT - rhetorical question; this response does not reprimand the client, but it does remind the client that they did agree to the time; the client's behavior is an example of the testing behavior

Kaplan Psychiatric Nursing 1 The nurse knows which statement is true regarding anorexia nervosa? a. Adolescent males are most affected. b. Anorexia nervosa has the highest mortality rate of all mental disorders. c. Clients diagnosed with anorexia nervosa see themselves as emaciated. d. Client diagnosed with anorexia nervosa are self-indulgent.

a. common in females 12-18 years old b. CORRECT - anorexia is fear of obesity, dramatic weight loss, distorted body image; 4-40% of clients diagnosed with anorexia nervosa die from self-imposed starvation and its sequel, involving fluid electrolyte imbalance and multiple organ system failure c. have distorted body image d. drastically reduce food intake and are preoccupied with foods that cause weight gain

Kaplan Psychiatric Nursing 1 The client is brought to the hospital by the spouse. The client is boisterous, quarrelsome, and unusually energetic. The spouse reports that in the past week the client has not slept more than three hours a night, and has been buying extravagant items that they cannot afford. Which understanding is basic to the care of the client with episodes of elation and depression? a. The client has nonspecific fears. b. The client is easily stimulated by the surroundings. c. The client has recurring unwanted thoughts. d. The client has a well-organized delusional system.

a. describes anxiety b. CORRECT - attention span is severely disturbed and the client is easily distracted; behaviors are characterized by flight of ideas and hyperactive activities; nursing care of clients with elation should focus on the fact that the client is in an extreme state of excitement and is easily stimulated c. indicates elation d. delusion is a persistent false belief

Kaplan Psychiatric Nursing 1 The nurse cares for clients in the mental health clinic. The client diagnosed with obsessive-compulsive disorder tells the nurse of being afraid of contracting AIDS. The client reports spending much of the day washing the hands and spraying disinfectant in the room. The nurse understands this hand-washing behavior represents which statement? a. A drive that needs to be denied. b. A dissociative response to trauma. c. A hidden wish to become ill and disabled. d. A symbolic expression of conflict and guilt.

a. drive is an internal or external stimulus that motivates the individual; obsession is a repetitive, uncontrollable thought; compulsion is repetitive uncontrollable action b. dissociation disconnects one part of memory from another c. hypochondirasis is over concern about one's health d. CORRECT - repetitive behavior is an attempt to control anxiety; accept client's ritualistic behavior, structure environment, offer alternative activities, especially ones using the hand

Kaplan Psychiatric Nursing 1 During the period of elation for the client diagnosed with bipolar disorder, which approach should the nurse plan to use frequently? a. Point out the effect a client's behavior has on others. b. Attempt to distract and redirect the client. c. Encourage the client to express himself. d. Provide opportunities for the client to socialize.

a. during manic periods, client has flight of ideas, is disoriented, talks excessively, jokes, dances, sings, is hyperactive; mood has no connection with reality or the feelings of others. b. CORRECT - attempting to distract and redirect the client is the proper course; clients with mania have a tremendous amount of energy for which they must have an outlet; attempts to confront or limit excessive activities usually lead to an increase in anger and frustration; by redirecting or distracting the client, the nurse recognizes the client's need for outlets, and demonstrates an acceptance and understanding of the manic individual's needs c. during manic phase, client able to express him/herself; important that the staff provide external controls; do not encourage client by laughing when they tell jokes or perform d. during manic phase, important to decrease stimuli; assign room away from activity, limit interactions with people; anticipate situation that will provoke or over-stimulate the client

Kaplan Psychiatric Nursing 1 The client responds incorrectly when a nurse asks the date and day of the week. The nurse BEST describes the client's mental state by which term? a. Euphoric b. Abivalent c. Incoherent d. Disoriented

a. exaggerated feeling of well-being b. contradictory feelings about a person or idea c. thinking in an illogical way; not understandable d. CORRECT - the person who is unaware of time and place is disoriented

Kaplan Psychiatric Nursing 1 Nursing care for the client diagnosed with substance abuse is based on which principle? a. The client has difficulty making decisions. b. The client expects too much of himself. c. The client attempts to appease others at all costs. d. The client has limited ability to tolerate anxiety.

a. have difficulty tolerating anxiety b. may have feelings of grandiosity, which is the irrational thought that one is entitled to special treatment c. a codependent focus on others without regards to personal needs or expectation d. CORRECT - clients who abuse drugs have a low frustration tolerance and use drugs to escape difficult feelings

Kaplan Psychiatric Nursing 1 The client is admitted to the hospital with a diagnosis of paranoid schizophrenia. The spouse states the client has not slept in three nights. Which nursing goal takes priority? a. Increase a sense of responsibility. b. Increase independence. c. Promote trust. d. Promote rest.

a. have to intervene first with schizophrenic's lack of trust because the schizophrenic views the world as hostile and threatening b. nurse has to start at the level of trust c. CORRECT - schizophrenic individuals are highly sensitive to fear of rejection; promoting trust is the nursing approach that should take priority d. schizophrenia causes psychosis, which is hallucinations or delusions with an absence of insight about their dysfunctional nature; have to intervene first with schizophrenic's lack of trust because the schizophrenic views the world as hostile and threatening.

Kaplan Psychiatric Nursing 1 The client is diagnosed with undifferentiated schizophrenia. In the day unit of an outpatient mental health program, the nurse finds the client dancing alone next to the radio. Suddenly, the client stops dancing and stares at the nurse in a menacing manner. Which action by the nurse is BEST? a. Leave for a short time promising to return soon. b. Remain silent and stand still until the client speaks. c. Start talking to the client about a neutral topic. d. Point out that the client has stopped dancing and seems upset.

a. important to validate reality; because client misinterprets reality, be very clear about communication, both verbal and nonverbal b. this behavior is ambiguous and would make the client more suspicious; communicate with a calm, authoritative tone; address the client by name c. always take the opportunity to validate reality when caring for schizophrenics d. CORRECT - presents reality and reflects feelings; the next remark might be, "Can you tell me what you are thinking about?" which describes an observation, and ask client for more information.

Kaplan Psychiatric Nursing 1 The nurse orients the client to the unit. The nurse observes the client is pacing, talking rapidly, and has elevated respirations. Which action by the nurse is BEST? a. Provide an informational booklet. b. keep the explanation simple c. delay the orientation until the anxiety has eased d. stress the positive aspects of the unit

a. leaving information to be read when anxiety is lower is appropriate, but the nurse should provide a brief verbal orientation b. CORRECT - anxious individual has very poor comprehension and an inability to concentrate; only part of what the nurse says will be remembered or retained; keeping explanations simple is therefore the best approach c. orient the client but do not overwhelm with information d. keep stimulation low when anxiety is high; acknowledge anxious behavior; reflect and clarify; stay with the client

Kaplan Psychiatric Nursing 1 The middle-aged client is admitted to the hospital with a diagnosis of terminal lung cancer. The client's spouse reports to the nurse that the client did not want to come to the hospital and "refuses to slow down." The nurse should give priority to which measure? a. Promote rest and relaxation. b. Encourage the client to participate in planning care. c. Encourage the client to accept help from others. d. Set limits on excessive activities.

a. more appropriate to allow client to participate in decisions about care b. CORRECT - this client obviously thrives on independence; would be most helpful to give client a sense of control over care; give choices wherever possible, and allow self-care when feasible c. encourage clients to be independent d. allow client to participate in decision-making

Kaplan Psychiatric Nursing 1 The client diagnosed with a phobic disorder joins a group meeting with a psychiatric nurse-leader. During the first meeting, the client states; "I know my feeling of being terrified of closed spaces is dumb. It doesn't make any sense. I just can't seem to do anything about it. Right now I get nervous and scared just thinking about it. "Which response by the nurse is BEST? a. "Having a nurse stay with you in a closed space could help you overcome your fear." b. "Knowing that your fears don't make sense doesn't always help you feel better." c. "Participating in several of our unit activities may make you feel better." d. "Being frightened as a child by some particular incident probably caused these fears."

a. nurse is offering a solution without acknowledging what the client is expressing; therapy for phobias includes exposure therapy to desensitize the client, hypnosis, and supportive therapy to help client actively confront phobic objects b. CORRECT - this communicates the best understanding of the client's dilemma; the client knows the fears do not make sense yet the client is powerless to deal with them c. does not address what client is expressing d. untrue statement phobia is an anxiety disorder and is not precipitated by being frightened as a child

Kaplan Psychiatric Nursing 1 The nurse finds the client diagnosed with schizophrenia standing in the dayroom of the psychiatric inpatient until completely undressed. Which measure by the nurse is BEST? a. Cover the client with a towel or sheet and send the client to get dressed. b. Lead the client back to the room and help the client get dressed. c. Ask the client why there seems to be a need for extra attention this morning. d. Take the client back to the room and privately reprimand the client.

a. schizophrenics have difficulty processing information; may not be able to sequence the steps required to get dressed b. CORRECT - the immediate nursing action is to take the client back to the room and get the client dressed; the behavior reflects regression common in schizophrenic clients c. asking "why" questions is nontherapeutic; this assumes that the client's behavior was purposeful d. important to maintain accepting attitude toward client; accept regression as a normal part of treatment

Kaplan Psychiatric Nursing 1 One of the nursing assistive personnel (NAP) on the unit is critical of a client admitted after an accidental overdose. The NAP says, "The client's family worries about the client but the client doesn't seem to care how anybody feels." Which response by the nurse to the NAP is BEST? a. "If we can make the client realize this, perhaps the client will get better." b. "Sometimes it's difficult to see how anxious the clients really are." c. "Perhaps the client's family has caused the client pain." d. "Being critical of the client is not going to help the client improve."

a. the underlying problem is anxiety b. CORRECT - it is important that the nursing staff involved with a client who has a personality disorder, or who is a substance abuser, realize that these clients have a grandiose or superficial facade that covers up underlying anxiety and insecurity; it is difficult to give nursing care, because these clients provoke anger and irritation; understanding the underlying symptoms and the client's need to manipulate others through fear and lack of trust helps the nurse care for this client c. client is feeling anxiety and insecurity d. while this is a true statement, understanding that anxiety is difficult to see is better becase it explains to the NAP why the client is responding in a certain way

Kaplan Psychiatric Nursing 1 During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down. Which approach by the nurse is BEST? a. Use small talk to keep the conversation going. b. Ask the client why the client is having difficulty talking. c. Ask concrete, direct questions that require simple answers. d. Use brad openings and leads to encourage discussion.

a. therapeutic communication explores the client's feelings, thoughts, and behaviors; engaging in small talk ("What the weather like?", "What did you have for lunch?", "Do you have big weekend plans?") dose not acknowledge the nonverbal behavior that the nurse observes b. "why" question may make a client defensive c. doesn't allow client to discuss thoughts and feelings d. CORRECT - in the initial phases of treatment, when the client appears anxious and self-conscious, broad openings and leads such as "What would you like to talk about?" help a client to talk and to maintain a sense of control

Kaplan Psychiatric Nursing 1 The nurse cares for clients on the medical/surgical unit. The nurse admits a client for possible appendicitis. During the admission interview the client states, "Most days I drink about one pint of vodka." The nurse knows when is the MOST likely time for the client to develop alcohol withdrawal delirium? a. 6-12 hours after cessation of drinking. b. 12-18 hours after cessation of drinking. c. 48-72 hours after cessation of drinking d. 4 days after cessation of drinking.

a. time frame for symptoms of withdrawal b. too soon for delirium to develop c. CORRECT - delirium occurs two to three days after not ingesting alcohol; symptoms include tremors, anxiety, panic, disorientation, confusion, paranoia, delusional symptoms, generalized tonic-clonic seizures, coma, and death; nurse should anticipate this occurrence, can be avoided with IV fluid and administration of sedatives/hypnotics d. Occurs sooner

Kaplan Psychiatric Nursing 1 The nurse volunteers in a homeless shelter. The nurse notices that another volunteer develops an overly close relationship with the older women in the shelter. During conversation, the volunteer relates to the nurse that several years before the volunteer's mother die, they refused to let their mother live in the volunteer's home. The nurse understands that the volunteer is using which defense mechanism? a. Substitution b. Undoing c. Compensation d. Denial

a. volunteer finds an alternative or substitute gratification; helps person through difficulty for a short time, but prevents personal growth and development b. CORRECT - "undoing" an action is an attempt by the volunteer to erase the action; this may be expressed by excessive apologies c. an attempt to overcome real or imagined shortcoming d. failure to acknowledge an intolerable thought, feeling, experience, or reality

Kaplan Psychiatric Nursing 1 One morning at a group therapy session, several clients begin to pick on another client for behaving passively. The nurse leader says the client is a very sensitive person who has problems, and they should stop picking on the client Which is the MOST likely effect of this statement? a. The client's isolation from the group will decrease. b. The client's insight into the group behavior will increase. c. The client's isolation from the group will increase. d. The client's participation in the group will increase.

a. will increase isolation b. attacking person will not increase his/her insight c. CORRECT - when trying to keep a passive or withdrawn client from being attacked in a group situation, the nurse should try to point out diplomatically that too much pressure is applied; in this situation, the nurse makes the mistake of making this client sound like a baby who cannot defend self; this will make the client even more subject to attack; ideally, attention should be diverted, or other members mobilized to take the attacked client's position d. attacking does not encourage participation