NCLEX Psych

The patient is prescribed paroxetine 25 mg by mouth daily and asks, "Why is my mouth so dry? Water does not help." What is the nurse's best response? a. "A side effect of paroxetine is dry mouth and throat. Have you tried sugar-free candies?" b. "Have you had your throat examined for an infection?" c. "The air in the hospital is very dry. Keep drinking lots of water." d. "I am sorry you are having discomfort. That must be from your depression."

a. "A side effect of paroxetine is dry mouth and throat. Have you tried sugar-free candies?" Paroxetine is a selective serotonin reuptake inhibitor prescribed for major depression, and one of the side effects is dry mouth and throat, which are associated with its anticholinergic effects. Although patients often do not find relief with oral brushing or drinking water, sugar-free candies are helpful to keep the oral cavity moist. Dry mouth is not associated with infection or depression.

How should the nurse respond when asked why alcohol withdrawal and detoxification should be managed in a hospital setting? a. "Alcohol withdrawal can be life-threatening and thus requires care provided by trained staff." b. "Patients prefer to be isolated from family and friends when experiencing the severe symptoms of withdrawal." d. "The cost of the treatment is covered by insurance only if delivered in a hospital setting." e. "Most often, neither families nor friends are willing and capable of managing the patient during the withdrawal."

a. "Alcohol withdrawal can be life-threatening and thus requires care provided by trained staff." Because alcohol withdrawal can be life-threatening, detoxification needs to be medically supervised. Although the other options may be true statements, none effectively addresses the seriousness of the withdrawal process and the possible risk to life that it presents.

A client brings a spouse to the mental health clinic with reports that the spouse has been exhibiting a tendency to self-mutilate, experiences fits of intense rage, and is increasingly aggressive toward others. How should the nurse elaborate on the type of symptoms this client is demonstrating? a. "Lack of serotonin in the body produces symptoms such as aggression, hostility, and compulsiveness." b. "Lack of dopamine in the body produces symptoms such as depression, fatigue, and lack of motivation." c. "Lack of norepinephrine in the body produces symptoms such as obesity, fibromyalgia, and panic attacks." d. "Lack of histamine in the body produces symptoms such as anxiety, hypertension, and difficulty regulating body temperature."

a. "Lack of serotonin in the body produces symptoms such as aggression, hostility, and compulsiveness." Serotonin plays a role in emotions, cognition, sensory perceptions, and essential biologic functions such as sleep and appetite. Serotonin also controls food intake, irritability, sleep and wakefulness, compulsiveness, temperature regulation, pain control, sexual behaviors, and regulation of emotions. Norepinephrine, histamine, and dopamine are not correct. Lack of norepinephrine may lead to conditions such as attention deficit hyperactivity disorder, depression, and hypotension. Lack of histamine means dopamine levels will be elevated and this may result in anxiety, paranoia, being suspicious, and hallucinations. Lack of dopamine may lead to imbalance difficulties, speech problems, and postural changes.

The patient asks the nurse, "What type of a disease is schizophrenia?" Which statement is the nurse's best response? a. "Schizophrenia is a syndrome that causes seizure activity." b. "Schizophrenia is a syndrome with many different types and symptoms." c. "Schizophrenia is a disease for which there are no treatments." d. "Schizophrenia is a debilitating mental health illness that results in homelessness."

a. "Schizophrenia is a syndrome that causes seizure activity." Schizophrenia is a known syndrome with variable symptoms, making individualized care essential. Historically, these patients were institutionalized due to their bizarre presentations. Schizophrenia does not necessarily lead to homelessness and is not associated with seizures. Treatments are available for schizophrenia.

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this? a. "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." b. "I am sure you know what I am thinking. Everybody knows what I am thinking." c. "My family is taking my thoughts away. I am unable to think now." d. "My dead friend is putting these ideas in my mind."

a. "The news of the terrorist attack is directed to me. The terrorists are trying to warn me." Ideas of reference are the inaccurate perception of the client that general events are personally directed to him or her. Thinking that the news of the terrorist is a warning to the client indicates that the client has ideas of reference. The delusion that other people (dead friend) are putting thoughts in the client's mind is referred to as thought insertion. The delusion that others are taking the client's thoughts away is referred to as thought withdrawal. The delusion that others know what the client is thinking is referred to as thought broadcasting.

The nurse is seeing a Chinese client who reports chronic pain that radiates to the lower back. The client reports the pain has been unresolved with analgesia, physical therapy and therapeutic massage. The client's diagnostic imaging reports are all unremarkable. Which statement by the nurse would be the most supportive response to this client? a. "You must be so frustrated with this unexplained pain. Do you have other stresses in your life too? b. "It would be best for your to see a specialist until the underlying issue is properly diagnosed." c. "The treatment that was recommended to you has worked for many clients. It is supported by research." d. "Is it common in your culture to talk about psychological distress like it is physical pain?"

a. "You must be so frustrated with this unexplained pain. Do you have other stresses in your life too? Whereas some evidence suggests that somatization is a result of abnormally high levels of physiologic response, other evidence supports the idea that somatization is the physical expression of personal problems or the internalization and expression of stress through physical symptoms. The nurse should use an approach that helps to establish trust through acknowledgment and validation. The therapeutic relationship is key. Telling the client the recommended treatment approach is supported by research may elicit a defensive reaction in the client, hindering the therapeutic relationship. Talking about culturally specific behaviors indicates the nurse is using stereotyping, a culturally incompetent approach. Encouraging the client to continue to seek multiple health care providers is ineffective and feeds into the client's beliefs about the illness. The client should be encouraged to be consistent with one, primary health care provider.

Symptoms of alcohol withdrawal typically begin within what time period after the cessation or marked reduction of alcohol intake by the chronic alcohol drinker? a. 12 hours b. 120 minutes d. 1 week e. 3 days

a. 12 hours Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake.

A patient who is taking an antipsychotic medication tells the nurse, "I am having difficulty with my leg; it keeps shaking." What is the priority intervention of the nurse? a. Administer a screening test for movement disorders. b. Administer the Hamilton Rating Scale for Depression. c. Ask the patient whether he or she has seizure pads placed on the bed. d. Ask the patient to stay in his or her room while a provider is called.

a. Administer a screening test for movement disorders. The Abnormal Involuntary Movement Scale (AIMS) is a screening tool administered to assess for side effects of antipsychotic medications. The AIMS will aid in discerning symptoms of tardive dyskinesia, indicating a movement disorder.

What characteristic behavior demonstrated by Mr. Davis is associated with Stage III withdrawal symptoms? (Select all that apply.) a. Admitting to visual hallucinations b. Near continuous pacing c. Experiencing tactile disturbances d. Hypothermia e. Disoriented by more than 2 calendar days

a. Admitting to visual hallucinations b. Near continuous pacing c. Experiencing tactile disturbances e. Disoriented by more than 2 calendar days Clinical manifestations of Stage III or severe withdrawal symptoms would include continuous pacing associated with agitation, both tactile and visual disturbances/hallucinations, and disorientation for date by 2 or more days. Oral temperature would be elevated.

A client is 5 feet 6 inches tall, weighs 105 pounds, exercises 4 hours per day, and does not engage in any binging or purging behaviors. The client believes that he or she is becoming obese and states, "I'm shocked that you think I'm underweight. You don't understand me." The most likely diagnosis for this client is what? a. Anorexia nervosa, restricting type b. Anorexia nervosa, binge eating, and purging type c. Eating disorder not otherwise specified d. Bulimia nervosa, nonpurging type.

a. Anorexia nervosa, restricting type Anorexia nervosa is characterized by a voluntary refusal to eat and a weight less than 85% of normal for height and age. Clients with anorexia nervosa, restricting type have a distorted body image, eat very little, and often obsessively pursue vigorous physical activity to burn "excess calories."

A nurse is caring for a white, 30-year-old man whose wife has recently died. The client has been diagnosed with clinical depression and is demonstrating insufficient coping skills. Which action by the nurse would be most important? a. Ask the client whether he is thinking about killing himself. b. Determine the client's risk of psychosis. c. Refer the client for long-term psychotherapy. d. Determine whether anyone in the client's family has had depression.

a. Ask the client whether he is thinking about killing himself. The nurse should first ask whether the client is thinking about killing himself, because statistics show that among young, recently widowed white men between the ages of 20 and 34 years, the suicide risk is 17 times higher than that of married men in that same age group. Social isolation and access to firearms play important roles in this group. Information related to psychosis, psychotherapy, or family history would be less of a priority at this time.

Schizophrenia is characterized by both positive and negative symptoms. Which of the following is an example of a positive symptom? a. Auditory hallucinations b. Flat affect c. Anhedonia d. Inability to focus

a. Auditory hallucinations Hallucinations and delusions are the positive symptoms of schizophrenia, as they reflect an excess or distortion of normal functions. Such symptoms can be treated with psychotropic medications. The other symptoms listed are negative or soft symptoms, meaning they reflect a loss or decrease of normal functions. Negative symptoms typically persist even after treatment.

What is the highest priority when educating the patient who is taking monoamine oxidase inhibitors? a. Avoidance of foods containing tyramine b. The purpose of frequent blood level draws c. Careful recognition of signs and symptoms of toxicity d. The need for fluid and sodium replacement

a. Avoidance of foods containing tyramine Tyramine is an amino acid naturally found in small amounts in protein-containing foods such as strong or aged cheeses; cured, smoked, or processed meats; pickled or fermented foods; soybeans and soy products; and dried or overripe fruits. Monoamine oxidase inhibitors block the breakdown of tyramine and may can cause a hypertensive crisis, which can be life threatening. Therefore, patients should be taught to avoid consuming foods that contain tyramine. The other answers are of lower priority because they are less likely to be life-threatening.

What term refers to the collection of symptoms that are associated with untreated alcohol withdrawal? a. Delirium tremens b. Wernicke's encephalopathy d. Korsakoff syndrome ee. Cardiac myopathy

a. Delirium tremens Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium—called delirium tremens. All of the remaining options are associated with physical reactions to chronic alcoholism.

A nurse is reviewing the medical history of a client diagnosed with somatic symptom disorder. Which would the nurse expect to find as a comorbid condition? a. Depression b. Bipolar disorder c. Sleep disorder d. Thought disorder

a. Depression Somatic symptom disorder frequently coexists with other psychiatric disorders, most commonly depression and anxiety. Others include panic disorder, mania, social phobia, obsessive-compulsive disorder, psychotic disorders, and personality disorders. Older adults are particularly high risk for comorbid depression.

Which would be most important for a nurse to do when caring for a client with somatic symptom disorder? a. Develop a sound, positive nurse-client relationship b. Administer prescribed pharmacotherapy c. Ensure adherence to counseling d. Assist in developing a daily routine

a. Develop a sound, positive nurse-client relationship Although administering prescribed pharmacotherapy, counseling, and assisting in developing a daily routine are important, the most crucial part of the plan of care is developing a sound, positive nurse-client relationship. Without the relationship, the nurse is just one more provider who fails to meet the client's expectations.

Which nursing interventions would best address Mr. Davis's safety issues if his CIWA-Ar score were to rise to 8 or above? (Select all that apply.) a. Dim the lighting in his room. b. Minimize all sources of noise in his room. c. Suction equipment is kept at the bedside. d. Institute falls precautions. e. Provide him with high protein, low fat meals.

a. Dim the lighting in his room. b. Minimize all sources of noise in his room. c. Suction equipment is kept at the bedside. d. Institute falls precautions. Assuring patient safety is the primary nursing responsibility. With the potential for seizures, both lighting and noise should be minimized in Mr. Davis' environment. His mental and physical state places him at increased risk for falls and aspiration, making those interventions necessary. His nutritional issues should be assessed and addressed when he is considered stable and through the withdrawal.

How can the nurse caring for Mr. Davis best provide the appropriate emotional care during his alcohol withdrawal? a. Ensure that his needs are met in a nonjudgmental manner. b. Assure him that the withdrawal process generally lasts no more than 96 hours. c. Encourage his family to spend time at his bedside. d. Remind him frequently that the signs and symptoms will lessen in severity.

a. Ensure that his needs are met in a nonjudgmental manner. It is a nursing obligation to provide nonjudgmental, supportive, empathetic, and comprehensive emotional care to all patients regardless of one's personal feelings. While family support is important, the increased stimulation resulting from their presence at the bedside is not generally encouraged. While the remaining options present accurate information about the nature and length of the withdrawal, neither statement addresses emotional support.

The patient has begun treatment with olanzapine and complains of muscle spasms in the neck as well as tremors. The nurse recognizes this as which of the following? a. Extrapyramidal side effects b. Neuroleptic malignant syndrome c. Agranulocytosis d. Orthostatic hypotension

a. Extrapyramidal side effects Extrapyramidal side effects are reversible movement disorders induced by neuroleptic medications, such as olanzapine. They include dystonic reactions (such as spasms of the neck muscles), pseudoparkinsonism (such as tremor), and akathisia (such as restless movement). Orthostatic hypotension, a nonneurologic side effect of antipsychotic medications, is a temporary drop in blood pressure, typically associated with sitting up or standing. Agranulocytosis, a potentially fatal side effect of the antipsychotic clozapine, is the failure of the bone marrow to produce adequate white blood cells. Neuroleptic malignant syndrome is a serious and frequently fatal condition seen in those being treated with antipsychotic medications. It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly creatine phosphokinase), and leukocytosis (increased leukocytes).

Which symptoms are consistent with a diagnosis of major depressive disorder? (Select all that apply.) a. Feelings of worthlessness b. Depressed mood c. Disruption in sleep d. Delusions e. Disruption in appetite

a. Feelings of worthlessness, b. Depressed mood, c. Disruption in sleep, e. Disruption in appetite DSM-5 diagnostic criteria for major depressive disorder include disruption in sleep (such as insomnia or hypersomnia), decrease or increase in appetite, feelings of worthlessness, and depressed mood. Delusions (false beliefs) are associated with psychosis, not major depressive disorder.

A nurse is engaged in a therapeutic relationship with a client. What should the nurse do in order to ensure therapeutic communication takes place? Select all that apply. a. Focus on the client during the interaction b. Ensure the client's confidentiality c. Give the client advice about what to do d. Use self-disclosure frequently for empathy e. Employ theoretically based interventions

a. Focus on the client during the interaction, b. Ensure the client's confidentiality, e. Employ theoretically based interventions A nurse engaged in therapeutic communication with a client should follow the principles of therapeutic communication: making the client the primary focus of the interaction; using self-disclosure cautiously and only when it serves a therapeutic purpose; maintaining client confidentiality; implementing interventions from a theoretic base; and avoiding the giving of advice.

When a client who is generally pleasant and cooperative begins to show aggressive behavior toward most clients in a community care facility, the nurse suspects the client has experienced cerebral trauma. Which brain structure is responsible? a. Frontal lobes b. Occipital lobes c. Limbic lobes d. Temporal lobes

a. Frontal lobes Frontal lobe damage shows symptoms that include loss of emotional control, rage, violent behavior as well as changes in mood and personality and uncharacteristic behavior. Thus, when a client who is generally pleasant and cooperative begins to show aggressive behavior toward most members of the milieu, the nurse suspects the client has experienced cerebral trauma to the frontal lobe. Temporal, occipital, and limbic lobe damage do not exhibit aggressive behavior or personality changes.

The parents of a toddler are distraught that the toddler has been diagnosed with autism spectrum disorder. When providing care for the child and the parents, the nurse understands that autism spectrum disorder is thought to be caused by what? a. Genetic factors b. Perinatal hypoxia c. Impaired attachment in infancy d. Immunizations containing mercury

a. Genetic factors Approximately 70% of idiopathic autism spectrum disorder cases appear to be an inherited form of an affective disorder. Studies also suggest that autism spectrum disorder is caused by interactions of multiple genes. The disorder is not caused by immunizations. Neither impaired attachment nor perinatal hypoxia has been identified as an etiologic factor.

According to DSM criteria, which of the following are characteristics of schizophrenia? (Select all that apply.) a. Hallucinations b. Compulsive behavior c. Delusions d. Disorganized behavior e. Disorganized speech

a. Hallucinations c. Delusions d. Disorganized behavior e. Disorganized speech The DSM-5 diagnostic criteria for schizophrenia state that at least one of the following must be present: delusions, hallucinations, or disorganized speech. Overall, the patient must present with two of the following: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, or negative symptoms (with one being mentioned earlier). Continuous signs must persist for 6 months and include two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. Compulsive behavior is not among the diagnostic criteria for schizophrenia.

When providing care for Mrs. Chen, the nurse realizes that patients of Asian descent often do not verbalize depressive symptoms but rather report them as which of the following symptoms? (Select all that apply.) a. Headaches b. Tiredness c. Overeating d. Imbalance e. Weakness

a. Headaches, b. Tiredness, d. Imbalance, e. Weakness People from different cultures express depressive symptoms in various manners. People from Asian cultures often do not report mood-related symptoms of depression but rather somatic symptoms, such as headache, weakness, tiredness, imbalance and other somatic complaints. Overeating is not a symptom of depression that people from Asian cultures would likely report.

Which area of the brain has been associated with the symptoms of eating disorders? a. Hypothalamus b. Cerebellum c. Pons d. Medulla

a. Hypothalamus The hypothalamus has been associated with the symptoms of eating disorders.

A client in the operating room goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is what? a. Hypothalamus b. Cerebellum c. Thalamus d. Midbrain

a. Hypothalamus The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. In addition, the hypothalamus is the site of the hunger center and is involved in appetite control.

Which nursing interventions are directly associated with the primary goals of the management of a patient, like Mr. Davis, who is currently experiencing alcohol withdrawal? (Select all that apply.) a. Keep SpO2 probe at bedside b. Identifying triggers for alcohol consumption c. Implement seizure precautions d. Provide information regarding AA support groups e. Assess and record heart rate every 4 hours

a. Keep SpO2 probe at bedside c. Implement seizure precautions e. Assess and record heart rate every 4 hours The primary goals of managing a patient with alcohol withdrawal are to maintain circulation, airway, breathing, and patient safety. Supportive measures should be provided as indicated by the patient's condition. Depending on the patient's condition after withdrawal symptoms resolve, alcohol dependence treatment such as AA groups and abuse triggers should be considered.

Which of the following is commonly included to reduce the potential relapse of schizophrenia in those who are being successfully treated with medications? (Select all that apply.) a. Milieu therapy b. Electroconvulsive therapy c. Social skills training d. Social support e. Coping skills

a. Milieu therapy c. Social skills training d. Social support e. Coping skills Electroconvulsive therapy is suggested as a possible alternative treatment for when the patient's schizophrenia is not being successfully treated by medication alone. For the most part, this is not indicated unless the patient is catatonic or has depression that is not treatable by other means. The development of coping skills, social support, social skills training and milieu therapy are all interventions that may be combined with successful medication treatment to help reduce the potential for relapse of schizophrenia.

Dietary modifications are most likely necessary when a client is being treated with which antidepressant? a. Monoamine oxidase inhibitors (MAOIs) b. Selective serotonin reuptake inhibitors(SSRIs) c. Tricyclic antidepressants d. Atypical antidepressants

a. Monoamine oxidase inhibitors (MAOIs) MAOIs are antidepressants that are well known for their multiple drug and food interactions. As such, dietary modifications are necessary. Such modifications are not normally necessary when a client is receiving SSRIs, tricyclic antidepressants, or atypical antidepressants.

A client with a blood alcohol level of 0.20 mg% is at a high risk for injury related to the impairment of which function? a. Motor b. Respiratory c. Orientation d. Consciousness

a. Motor Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. With a blood alcohol level of 0.20 mg%, the client is at risk for injuries related to severely impaired motor function. Consciousness and orientation are affected when levels rise to 0.30 mg%. Respiratory failure is possible with a blood alcohol level of 0.50 mg%.

A nurse provides care to a client with schizoaffective disorder during hospitalization for acute psychosis. Nursing interventions to help the client to establish trust with the health care team is best accomplished by what? a. Offering reassurance in a soft, nonthreatening voice b. Reminding the client that delusions are not real c. Encouraging the client to participate in group therapy daily d. Decrease stressful situations by controlling the client's symptoms

a. Offering reassurance in a soft, nonthreatening voice During periods of acute psychosis, offering reassurance in a soft, nonthreatening voice and avoiding confrontational stances will help the client begin to trust the staff and nursing care.

The patient was recently diagnosed with schizophrenia, began treatment, and has gained 10 pounds in the last month. Which medication is most likely responsible for the patient's weight gain? a. Olanzapine b. Fluoxetine c. Paroxetine d. Lithium carbonate

a. Olanzapine Antipsychotic medications, such as olanzapine, are associated with numerous side effects, including weight gain. Paroxetine and fluoxetine are antidepressants, not antipsychotics, and are not associated with weight gain. Lithium carbonate is used to treat the manic phases of bipolar disorder.

Which of the following should the nurse encourage Mr. and Mrs. Chen to do when she is discharged (depression/SI)? a. Participate in individual or group therapy. b. Urge Mr. Chen to take on more household chores. c. Encourage Mrs. Chen to rest as much as possible during the first weeks after discharge. d. Suggest a variety of jobs for Mrs. Chen outside the home.

a. Participate in individual or group therapy. For patients to decrease the likelihood of relapse, they are encouraged to problem solve and find their own solutions; participating in individual or group therapy can help accomplish this. This approach contributes to the patient's sense of self-worth. Encouraging Mr. Chen to do the chores would likely decrease Mrs. Chen's sense of self-worth. Allowing Mrs. Chen to choose a job outside the home herself would be more effective than suggesting a variety of jobs to her. Too much time spent alone and unproductive could trigger another depressive episode in Mrs. Chen.

Which zone is an acceptable distance between a speaker and an audience? a. Public b. Personal c. Social d. Intimate

a. Public The public zone is an acceptable distance between a speaker and an audience. The intimate zone is the amount of space that is comfortable for parents with young children and people who mutually desire personal contact. The personal zone is the distance comfortable between family and friends who are talking. The social zone is the distance acceptable for communication in social, work, and business settings.

A client is receiving lithium carbonate for the treatment of mania. The nurse would reinforce which teaching component regarding lithium treatment? a. Schedule bloodwork for lithium levels. b. Give medication on an empty stomach. c. Watch for low urine output. d. Decrease fluid intake to prevent edema.

a. Schedule bloodwork for lithium levels There is a narrow range between therapeutic lithium levels and lithium toxicity. It is important to obtain scheduled drug levels to prevent toxicity from occurring. The nurse should monitor for polyuria. Teaching includes taking the medication with food or milk after meals and ensuring an adequate daily intake of fluid (2,500 to 3,000 mL) daily.

A nursing student is caring for an elderly client who is taking sertraline for depression. The instructor quizzes the student about the medication and its actions. To what classification of drugs should the student assign sertraline? a. Selective serotonin reuptake inhibitor b. Serotonin 2 antagonist c. Monoamine-oxidase inhibitor d. Cyclic antidepressant

a. Selective serotonin reuptake inhibitor Sertraline is a selective serotonin reuptake inhibitor.

Which type of intervention may be helpful for children who are bullies? a. Social skills training b. Play therapy c. Art therapy d. Bibliotherapy

a. Social skills training Social skills training may be particularly helpful for children who are bullies or rejected by their peers.

A 55-year-old client was admitted to the psychiatric unit after an incident in a department store in which the client accused a sales clerk of following the client around the store and stealing the client's keys. The client was subdued by the police after destroying a window display because voices had told the client that it was evil. As the nurse approached the client, the client says, "You're all out to get me, and you're one of them. They're Rostoputians and grog babies here." This demonstrates what? a. Suspiciousness and neologisms b. Echolalia and echopraxia c. Loose associations and flight of ideas d. Illusions and loss of ego boundaries

a. Suspiciousness and neologisms The client is demonstrating suspiciousness ("you're all out to get me") and neologisms (use of the words "Rostoputians and grog babies"). Loose associations and flight of ideas occur when the client talks about many topics in rapid sequence, but they are not connected with each other. Illusions are when the client sees something that is not there; echolalia is the repetition of words (or words that sound similar) said by someone else.

The nurse is sitting behind a table while speaking to a client on the other side of the table. What is the most appropriate reason for this nurse's action? a. The client may have difficulty maintaining spacial boundaries. b. The client can open up easily. c. The client can communicate freely. d. The client may be physically expressive.

a. The client may have difficulty maintaining spacial boundaries. Sitting behind a table while speaking to a client makes the setting formal. This setting would most likely be required when dealing with clients who have difficulty maintaining boundaries. Such a formal setting would make the client more uncomfortable. In such settings, the client may not be able to share feelings freely or to open up easily. It is not appropriate for the nurse to use this kind of setting if the client is willing to express individual feelings.

Mr. Davis reported having consumed his last drink around 4 pm, and he was admitted to the facility's detoxification unit shortly thereafter. What clinical manifestations of alcohol withdrawal should the nurse expect him to demonstrate by 10 pm that night? a. The signs and symptoms are likely to increase in type and severity. b. The majority of his withdrawal will consist of signs and symptoms similar to the current ones. c. He is likely currently experiencing the peak of his signs and symptoms. d. His signs and symptoms will likely taper off in severity over the next 12 hours

a. The signs and symptoms are likely to increase in type and severity. Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. The signs and symptoms of alcohol withdrawal gradually intensify and usually peak on the second day and are over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Since Mr. Davis has been without alcohol for an estimated 6 hours, his clinical manifestations are very likely to increase in both type and severity.

Benzodiazepines work by the following mechanism of action: a. They act directly on GABA receptors and are thought to increase the amount of GABA available. b. The mechanism of action of this category of drugs is unknown at this time. c. They act indirectly through a second messenger to affect levels of circulating GABA. d. They act directly on dopaminergic neurons in the medulla.

a. They act directly on GABA receptors and are thought to increase the amount of GABA available. Benzodiazepines act directly on GABA receptors and are thought to increase GABA available to dampen neural overstimulation.

Mr. Chen is anxious about his wife being home alone when he travels. He asks whether a visiting nurse would be helpful. Which of the following should the nurse mention regarding community-based supports? (Depression/SI) a. They aid patients by providing structure and assessment. b. They are only available when patients do not have a family. c. They will discourage patients from caring for themselves. d. They can be intrusive and unwelcomed by many patients and make symptoms worse.

a. They aid patients by providing structure and assessment. Community-based health care workers often notice subtle changes in a patient's condition or emotional state and are a valuable resource for any patient. They are not typically intrusive or unwelcomed and are available to anyone, not just those who do not have a family. In addition to providing care, they can also promote self-care in the patient.

The nurse is meeting a client for the first time. Which action should the nurse take to establish a rapport with this client? Select all that apply. a. shaking the client's hand when greeting b. remaining neutral when the client states a lack of faith in medical care c. suggesting the client obtain a second opinion if care is not satisfactory d. asking the client to further explain a recurring symptom e. defending the healthcare provider's choice of treatment

a. shaking the client's hand when greeting b. remaining neutral when the client states a lack of faith in medical care d. asking the client to further explain a recurring symptom Nurses establish rapport through interpersonal warmth, a nonjudgmental attitude, and a demonstration of understanding. Shaking the client's hand demonstrates interpersonal warmth. Understanding is demonstrated by asking the client to further explain a recurring symptom. Remaining neutral when the client states a lack of faith in medical care demonstrates a nonjudgmental attitude. Defending the healthcare provider's choice of treatment and suggesting the client obtain a second opinion if care is not satisfactory are behaviors that do not support the establishment of rapport.

Mr. Carter is at the window and states, "The voices are telling me to jump out the window." Which is the best response from the nurse? a. "When did the voices start?" b. "I am sorry; you must be scared. I will stay here with you to keep you safe." c. "Do not jump. I will call security." d. "Do not listen to them; ignore what they are saying."

b. "I am sorry; you must be scared. I will stay here with you to keep you safe." Reflecting the experience of hallucinations to the patient shows empathy and helps him or her feel validated. Safety is the first priority, so the nurse should stay with a patient who is having command hallucinations. Calling security is necessary, but the patient may feel judged being told not to jump.

Mr. Chen asks the nurse whether light therapy would be helpful for his wife. What is the nurse's best response? a. "There is no evidence to support the use of light therapy with patients diagnosed with depression." b. "Light therapy is known to be effective for patients with mild-to-moderate depression associated with seasonal onset." c. "Light therapy may make her symptoms worse." d. "Why do you ask about light therapy? Do you not agree with the medications?"

b. "Light therapy is known to be effective for patients with mild-to-moderate depression associated with seasonal onset." Light therapy is a newer treatment of choice and has been found to be effective in patients with depressive symptoms, especially in the darker months.

A client receiving an antipsychotic agent develops acute extrapyramidal symptoms. Which response by the nurse would be most appropriate? a. "You have developed an allergy to the medication, so we need to change it." b. "These are the results of the drug and can be treated; your illness is not getting worse." c. "The sunlight together with the medication has caused these symptoms; just stay indoors." d. "These symptoms are not real; the medication makes your brain think they are real."

b. "These are the results of the drug and can be treated; your illness is not getting worse." Individuals with acute extrapyramidal symptoms need frequent reassurance that these are not a worsening of their psychiatric condition but instead are treatable side effects of the medication. They also need validation that what they are experiencing is real and that the nurse is concerned and will be responsive to changes in these symptoms. Extrapyramidal symptoms are not indicative of an allergy. Photosensitivity occurs with antipsychotic agents and sunlight.

A client with schizophrenia is prescribed clozapine because other prescribed medications have been ineffective. After educating the client and family about the drug, the nurse determines that the education was successful when they state: a. "The client needs to have an electrocardiogram periodically when taking this drug." b. "We'll need to make sure that the client has the client's blood count checked at least weekly." c. "The client might develop toxic levels of the drug if the client smokes cigarettes." d. "We need to watch to make sure that the client doesn't lose too much weight."

b. "We'll need to make sure that the client has the client's blood count checked at least weekly." Clozapine is associated with agranulocytosis, so clients taking clozapine should have regular blood tests. White blood cell and granulocyte counts should be measured before treatment is initiated, and at least weekly or twice weekly after treatment begins. Although cardiac dysrhythmias can occur, they are more likely to occur with ziprasidone. Cigarette smoking can reduce the concentration of clozapine, thus necessitating a higher dose of this medication. Clozapine is associated with weight gain, not weight loss.

The patient's parents ask why their child has not been given the diagnosis of schizophrenia when symptoms point to this diagnosis. The nurse should explain that continuous signs of the disturbance must persist for how many months, including at least 1 month of symptoms, before diagnosis can be made? a. 9 b. 6 c. 3 d. 12

b. 6 According to the DSM-5, continuous signs of the disturbance must persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.

Which client is most likely to benefit from treatment with an antiparkinsonism agent? a. A client who is scheduled to begin electroconvulsive therapy (ECT) for the treatment of major depression b. A client who has a medication-induced movement disorder c. A client who is being treated with an atypical antidepressant d. A client who has been admitted to the hospital with a diagnosis of lithium toxicity

b. A client who has a medication-induced movement disorder Antiparkinsonism agents have been used to treat medication-induced movement disorders, such as neuroleptic-induced parkinsonism. The presence of lithium toxicity or the use of antidepressants or ECT is not likely to necessitate the use of antiparkinsonism agents.

In reviewing Mr. Carter's medications, the provider mentions possibly changing to Clozapine. The nurse understands that which side effect must be monitored closely with this medication? a. Anemia b. Agranulocytosis c. Prodromal seizure activity d. Hypertensive crisis

b. Agranulocytosis Agranulocytosis, a life-threatening complication of clozapine, is an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count), which increases the risk of serious infections due to the suppressed immune system. If the patient's absolute neutrophil count is below 1.0, the medication will be discontinued.

A loss of pleasure or interest in a client diagnosed with depression would be documented as what? a. Flat affect b. Anhedonia c. Discouragement d. Hopelessness

b. Anhedonia A person with depression has a sustained period of feeling depressed, sad, or hopeless and may experience anhedonia (loss of interest or pleasure). The client may report "not caring anymore" or not feeling any enjoyment in activities that were previously considered pleasurable. Flat affect is the complete or near absence of affective expression. Hopelessness and discouragement would not be the correct documentation for this symptom.

Mrs. Chen has been admitted after her third suicide attempt. What is the nurse's priority assessment for Mrs. Chen? a. Assess Mrs. Chen for appropriate coping skills. b. Assess Mrs. Chen for suicidality. c. Assess Mrs. Chen for support systems. d. Assess Mrs. Chen for vitamin D deficiency.

b. Assess Mrs. Chen for suicidality. The risk of successful suicide increases in lethality each time there is another attempt. Mrs. Chen has now had three attempts. Although the other answers represent important assessments, none is as important as assessing for suicidality.

Which medication is used to control the extrapyramidal effects associated with antipsychotic medications? a. Haloperidol b. Benztropine c. Chlorpromazine d. Thioridazine

b. Benztropine Benzotropine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia.

A nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which would the nurse most likely document? a. Above average intelligence b. Body complaints c. Disorientation d. Reduced attention span

b. Body complaints Somatic delusions involve bodily functions or sensations, with clients believing that they have physical ailments. Clients with delusional disorder show few, if any, psychological deficits. These clients characteristically have average or marginally low intelligence. Mental status generally is not affected. Thinking, orientation, affect, attention, memory, perception, and personality are generally intact.

After Mrs. Chen has been discharged for 3 days, she tells her husband, "I do not know what is wrong with me. I keep thinking about overdosing and feel so helpless." What is the priority for Mr. Chen? (Depression/SI) a. Give Mrs. Chen the as-needed antianxiety medicine per the discharge paperwork. b. Call 911 as instructed by the discharge nurse, because Mrs. Chen may be suicidal. c. Give Mrs. Chen some warm tea and suggest she lie down. d. Call the nurse on the floor to ask whether Mrs. Chen can attend a day program.

b. Call 911 as instructed by the discharge nurse, because Mrs. Chen may be suicidal. At discharge, it is important for the family to be told the signs of suicidal thoughts and develop a safety plan. Because Mrs. Chen has had multiple suicidal attempts, her thoughts about overdosing and feeling hopeless are signs of relapse and possible suicidality. Therefore, Mr. Chen should call 911. The other responses are not appropriate.

The patient has been prescribed sertraline and venlafaxine. The nurse recognizes that these medications given together can cause which condition? a. Dry mouth b. Confusion c. Hypervigilance d. Bradycardia

b. Confusion Serotonin syndrome should be considered when more than one SSRI (or an SSRI and any other type of serotonin-increasing medication) are given together. Symptom onset is rapid and typically occurs a short time after elevated serotonin levels. Symptoms of serotonin syndrome include the following: confusion and agitation (not hypervigilance), muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, muscle paralysis, hyperthermia, tachycardia (not bradycardia), tachypnea, hypersalivation (not dry mouth), and diaphoresis.

Which is the most common disorder found in clients diagnosed with bulimia nervosa? a. Psychosis b. Depression c. Substance abuse d. Anxiety

b. Depression Mood disorders, anxiety disorders, and substance abuse/dependence are frequently seen in clients with eating disorders. Of those, depression and obsessive-compulsive disorder are most common.

Some patients with schizophrenia display a bizarre speech pattern. Which pattern below is characterized by the patient repeating what the nurse has said to him or her? a. Echopraxia b. Echolalia c. Neologism d. Word salad

b. Echolalia Echolalia is repeating what someone else says. Neologism is when a patient makes up a nonsensical word for something. Echopraxia is mimicking movement of someone else. Word salad is multiple words in a sentence without conjoining meaning.

When patients are admitted to a locked psychiatric unit, which action should be the nurse's priority intervention? a. Complete the admission data tool. b. Ensure that patients and their belongings have been searched. c. Give the patients a tour so that they will be more comfortable. d. Educate the patient on the rules of the unit.

b. Ensure that patients and their belongings have been searched. Safety of the milieu and the patients is the top priority. New patients must be checked for contraband to ensure the safety of both the new patient and the others on the unit. The other answers are of lower priority than the patient's safety.

What is the primary reason that patients stop taking antipsychotic medications? a. Weight loss b. Extrapyramidal side effects c. Inability to pay for medication d. Stigma that is involved when using these medications

b. Extrapyramidal side effects Although many of the antipsychotic medications cause weight gain, the degree of extrapyramidal side effects (acute dystonic reactions, akathisia, and pseudoparkinsonism) can be life-altering, and if they develop, patients often discontinue the medication on their own.

Mr. Carter, who is diagnosed with schizophrenia, is exhibiting paranoid behavior. Which nursing intervention is a priority? a. Have Mr. Carter sit and review the side effects to the medication. b. Form a therapeutic relationship through brief, frequent interactions with Mr. Carter. c. Give Mr. Carter written instructions on the medications. d. Remind Mr. Carter that the nurse follows the provider's orders.

b. Form a therapeutic relationship through brief, frequent interactions with Mr. Carter. Forming a therapeutic relationship aids in the care and decreases the amount of paranoia. Mr. Carter would not be able to tolerate sitting, reading directions, or being told what to do. Spending 5 minutes at a time with Mr. Carter is likely an effective way to build trust with him.

A nurse is studying the brain images of children with attention deficit hyperactivity disorder (ADHD). In these images, the nurse would find abnormalities related to which area of the brain? a. Temporal lobe b. Frontal lobe c. Parietal lobe d. Occipital lobe

b. Frontal lobe Studies have proven that ADHD is associated with malfunction of the frontal lobe. Decreased metabolism and decreased perfusion to the frontal lobe are the physiological alterations known to cause ADHD. Dysfunction of the parietal lobe would cause abnormalities in sensory perception. Dysfunction of the occipital lobe would cause abnormalities in vision. Dysfunction of the temporal lobe would cause dysfunction in communication.

A patient with schizophrenia was recently prescribed clozapine and has begun taking the medication. The patient's absolute neutrophil count (ANC) this morning was 0.5. What is the nurse's priority intervention? a. Weigh the patient. b. Hold the next dose and call the provider. c. Start an intravenous line for fluid administration. d. Give the next dose sooner.

b. Hold the next dose and call the provider. A low ANC represents a critically low white blood cell count and, in this case, is likely the result of agranulocytosis (failure of the bone marrow to produce adequate white blood cells). This is a potentially fatal side effect of clozapine. When the ANC is below 1.0, the nurse should hold the next dose and call the provider immediately. Giving the next dose sooner would only aggravate the problem. Fluid administration and weighing the patient would not address low white blood cell count.

When describing the major difference between somatic symptom disorder and factitious disorders, which would the nurse include? a. In factitious disorders, clients are unaware that their symptoms are not real. b. In somatic symptom disorder, clients are not consciously aware that needs are being met through physical complaints. c. Factitious disorders respond much more readily to psychopharmacologic treatment than does somatic symptom disorder. d. In somatic symptom disorder, clients consciously seek attention.

b. In somatic symptom disorder, clients are not consciously aware that needs are being met through physical complaints. Clients with somatic symptom disorder do not intentionally cause, and have no conscious or voluntary control over, their symptoms. Lack of voluntary control is in contrast to factitious disorder and malingering. In factitious disorder, clients deliberately make up or inflict symptoms.

A nurse is conducting an inservice presentation for a group of newly hired mental health nurses. Which would the nurse most likely include when describing conversion disorder (functional neurologic symptom disorder)? a. The symptoms follow a typical neurologic pattern. b. Laboratory and diagnostic test results are usually negative. c. Symptoms expressed reflect a neurologic illness. d. The client's complaints are not real.

b. Laboratory and diagnostic test results are usually negative. Functional neurologic symptom disorder (or conversion disorder) is a psychiatric condition in which severe emotional distress or unconscious conflict is expressed through physical symptoms (APA, 2013). Clients with conversion disorder have neurologic symptoms that include impaired coordination or balance, paralysis, aphonia (inability to produce sound), difficulty swallowing, a sensation of a lump in the throat, and urinary retention. They also may have loss of touch, vision problems, blindness, deafness, and hallucinations. In some instances, they may have seizures (Nielsen, Stone, & Edwards, 2013). However, laboratory, electroencephalographic, and neurologic test results are typically negative. The symptoms, different than those with an organic basis, do not follow a neurologic course but rather follow the person's own perceived conceptualization of the problem.

A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy? a. White blood cell (WBC) count b. Liver function c. Cardiac enzymes d. Thyroid level

b. Liver function Baseline liver function tests and a complete blood count with platelets should be obtained before starting therapy, and clients with known liver disease should not be given divalproex sodium. There is a boxed warning for hepatotoxicity. Thyroid level, WBC count, and cardiac enzymes do not have to be performed routinely before starting this medication.

What is the average age of peak onset of symptoms of schizophrenia? a. There is no average age b. Men 15-25 years and women 25-35 years c. Men 40+ years and women 30+ years d. Men 12-40 years and women 16-25 years

b. Men 15-25 years and women 25-35 years Men develop symptoms earlier in life, with peak onset from 15 to 25 years of age, and therefore have a more difficult treatment and recovery. The peak onset of symptoms for women is from 25 to 35 years of age. The older the patient is when symptoms first appear, the better the prognosis.

The nurse is planning a presentation about suicide to a group of health professionals. Which should be included in the nurse's teaching plan? a. The most common method of committing suicide is the use of sleeping pills. b. Men are more likely to commit suicide than women are. c. Suicide tends to be most prevalent in the those in the age group of 30 to 40. d. Suicide rates for women are highest among women with children

b. Men are more likely to commit suicide than women are. The nurse should include in the teaching plan that men are four times more likely to commit suicide than women are. Suicide rates are highest in the age group of 15 to 24. Firearms contribute to high rates of suicide among adolescents.

What nursing intervention would most likely improve the therapeutic relationship between the nurse and a patient experiencing alcohol withdrawal by increasing the nurse's self-awareness? a. Providing prompt, effective nursing care for the patient with a history of alcohol abuse b. Monitoring one's own biases and reactions regarding alcoholism c. Providing empathetic care for the patient in alcohol withdrawal d. Regularly reviewing research results regarding the triggers for chronic alcoholism

b. Monitoring one's own biases and reactions regarding alcoholism Increasing one's self-awareness requires that the nurse examine his or her beliefs and attitudes about alcohol abuse. Monitoring one's own reactions to the patient allows for such ongoing self-awareness and evaluation. All the other options are appropriate nursing interventions but all are focused on the patient rather than the nurse.

A nurse is providing discharge teaching to Mr. Carter related to his new medication, fluphenazine, including one of its potential side effects, neuroleptic malignant syndrome (NMS). Which signs and symptoms associated with NMS should the nurse mention to Mr. Carter and his family to look out for? (Select all that apply.) a. Malaise b. Muscle rigidity c. High fever d. Ulcerative sore throat e. Seizures

b. Muscle rigidity c. High fever NMS is a serious and frequently fatal condition seen in those being treated with antipsychotic medications, such as fluphenazine. It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly creatine phosphokinase), and leukocytosis (increased leukocytes). Ulcerative sore throat and malaise are signs of agranulocytosis, a side effect specifically associated with the antipsychotic clozapine. Seizures are an infrequent side effect of antipsychotics and are not associated with NMS.

Mr. Carter is disheveled and has not showered in 4 days. Given his diagnosis, which of the following are likely causes of his self-care deficit? (Select all that apply.) a. Laziness b. Negative symptoms c. Lack of access to a washer and drier d. Disorganized thought processes e. Psychosis

b. Negative symptoms d. Disorganized thought processes e. Psychosis Someone whose thoughts are disorganized, who is psychotic, or who is experiencing negative symptoms associated with schizophrenia (avolition) may not have the ability to tend to activities of daily living.

A client is diagnosed with somatic symptom disorder. Which would the nurse expect to assess as the major clinical finding? a. The client's inability to focus on emotional content b. Report of symptoms with no demonstrable pathology on testing or examination c. Loss of voluntary motor or sensory functioning d. Definitive medical finding with a history of "doctor shopping"

b. Report of symptoms with no demonstrable pathology on testing or examination There are no positive lab or diagnostic tests indicating an organic cause of the physical symptom. The cause is psychological, which does not show on diagnostic testing. Although the client may "provider shop," there is no evidence or definitive finding to support the symptoms.

When reviewing the diagnostic criteria for schizophrenia based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), which would be most accurate? a. Schizophrenia can be diagnosed as soon as an individual states he or she is hearing voices. b. Schizophrenia lasts at least 6 months and includes at least 1 month of two or more characteristic symptoms. c. Schizophrenia can be diagnosed as soon as an individual states he or she is hallucinating and delusional. d. Schizophrenia lasts at least 1 month and must include the symptom of hallucinations.

b. Schizophrenia lasts at least 6 months and includes at least 1 month of two or more characteristic symptoms. According to the DSM-V, schizophrenia lasts at least 6 months and includes at least 1 month of two or more characteristic symptoms (e.g., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) and negative symptoms (e.g., diminished emotional expression, alogia, or avolition).

Mrs. Chen is being discharged with orders for sertraline and venlafaxine. During discharge teaching, the nurse should make it a priority to ensure that the patient recognizes which symptoms that indicate a problem with the medication? a. Serotonin withdrawal b. Serotonin syndrome c. ETOH withdrawal d. Hypertensive crisis

b. Serotonin syndrome Serotonin syndrome should be considered when more than one selective serotonin reuptake inhibitor (SSRI)—or an SSRI and any other type of serotonin-increasing medication— are given together. Symptom onset is rapid and typically occurs a short time after elevated serotonin levels. Symptoms of serotonin syndrome include the following: confusion and agitation (not hypervigilance), muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, muscle paralysis, hyperthermia, tachycardia (not bradycardia), tachypnea, hypersalivation (not dry mouth), and diaphoresis. Eating foods containing tyramines while taking a monoamine oxidase inhibitor (MAOI) can lead to a hypertensive crisis. Serotonin withdrawal would occur if the patient were to stop taking an SSRI. Taking sertraline and venlafaxine together would not cause ethanol (ETOH) withdrawal.

Of the following clinical information, which one would be the most important in determining whether the client would be diagnosed with a mental disorder? a. The client has been receiving good grades in college and has a grade point average of 3.8. b. The client is unable to continue school work and has been sitting on the client's bed for 3 days. c. The client's father died in a tragic automobile accident when the client was 10 years old. d. The client used cocaine up until 1 week ago.

b. The client is unable to continue school work and has been sitting on the client's bed for 3 days. Disturbance in functional status, or activities of daily living, is the most important factor in determining whether or not a mental disorder is present. Other data in the answers listed could be present even in the absence of mental disorder.

A psychiatric-mental health nurse has entered a client's room, made an introduction, and asked if the nurse and the client could speak for a few minutes. The clients states, "Yep. Glad to talk." However, the nurse observes that the client is looking at the floor and the client's arms and legs are crossed. How should the nurse best interpret this situation? a. The client is eager to dialogue with the nurse but is unsure how best to proceed b. The client may be reluctant to dialogue despite the statement to the contrary c. The disconnect between the client's verbal and nonverbal messages confirms the presence of mental illness d. The client is glad to talk to the nurse because that is what the client stated

b. The client may be reluctant to dialogue despite the statement to the contrary In general, nonverbal messages supersede verbal messages. This disconnect between the two types of communication, however, are not limited to persons with mental illness.

The nurse is caring for a client with severe depression. The client tells the nurse, "I really just want to sleep and not have to wake up." What may the nurse interpret from this covert cue? a. The client may be extremely fatigued. b. The client may have suicidal ideations. c. The client may need a break to reduce stress. d. The client may want to sleep.

b. The client may have suicidal ideations. Covert cues are often vague messages that require interpretation from the nurse or other health care professional. As the client has severe depression, it is possible the client is discussing suicide. The nurse needs to ask a direct yes or no question to determine if this is truly the case. The nurse may be able to surmise that this client is not discussing sleep, fatigue, or needing a break from stress.

A client with complex somatic symptom disorder is complaining of significant pain in the joints. When providing care to this client, which would be most important for the nurse to keep in mind? a. Complementary therapies are usually of little benefit. b. The client's experience of pain is real. c. Opioid analgesics are the primary mode of therapy. d. Outcomes need to reflect the biologic aspects of the pain.

b. The client's experience of pain is real. Even though there is no medical explanation for the pain, the client's pain is real and has serious psychosocial implications. Aggressive pharmacologic treatment of the symptoms must be avoided. Nonpharmacologic strategies, including complementary and alternative treatments, should be used to assist in pain relief. Outcomes developed need to avoid focusing on the biologic aspects of the disorder and instead help the client overcome the pain through biopsychosocial approaches.

The nurse is caring for a patient with schizophrenia. Orders from the provider are for chlorpromazine 100 mg intramuscularly STAT and benztropine 50 mg by mouth twice daily as needed. Which of the following assessments would convey to the nurse the need to administer the as-needed benztropine? a. The patient's skin develops a yellowish tone. b. The patient develops a shuffling gait and tremors. c. The patient's level of agitation increases. d. The patient complains of a sore throat.

b. The patient develops a shuffling gait and tremors. A shuffling gait and tremors are hallmark symptoms of extrapyramidal side effects brought on by the chlorpromazine, a typical antipsychotic. Benztropine is a medication that treats extrapyramidal side effects in patients taking antipsychotic medications. Agitation, sore throat, and jaundice (yellowish skin tone) are not extrapyramidal side effects and thus would not be treated with benztropine.

The primary care provider states that a patient with schizophrenia needs an AIMS exam. The nurse recognizes that this tool is used for which purpose? a. To screen for discharge planning needs, including a shelter b. To screen for movement disorders caused by antipsychotic medications c. To screen for obsessive-compulsive disorder d. To screen for a personality disorder inhibiting the antipsychotic medicine

b. To screen for movement disorders The Abnormal Involuntary Movement Scale (AIMS) is a screening tool administered to check for movement disorders, including those that occur as side effects of antipsychotic medications. The AIMS exam aids in discerning symptoms of tardive dyskinesia, which indicate a movement disorder.

Which is most often the criterion for determining the effectiveness of treatment in the client diagnosed with anorexia nervosa? a. Increased activity b. Weight gain c. Positive self-esteem d. Mood elevation

b. Weight gain Weight gain is most often the criterion used for determining the effectiveness of treatment in the client diagnosed with anorexia nervosa.

Some patients with schizophrenia display a bizarre speech pattern. Which pattern below is characterized by the patient saying random words and phrases that are disconnected and do not have meaning to the listener? a. Echopraxia b. Word salad c. Echolalia d. Neologism

b. Word salad Word salad is a speech pattern in which the person says random words and phrases that are disconnected or incoherent and make no sense to the listener. Neologism is when a patient makes up a new word for something. Echopraxia is mimicking the movement of someone else. Echolalia is repeating what someone else says.

A nurse is interviewing a client with schizophrenia when the client begins to say, "Kite, night, right, height, fright." The nurse documents this as: a. stilted language. b. clang association. c. verbigeration. d. neologisms.

b. clang association. The client is manifesting clang association, which is the repetition of words or phrases that are similar in sound but are in no other way connected. Stilted language is the use of overly and inappropriate artificial formal language. Verbigeration is the purposeless repetition of words or phrases. Neologisms are words that are made up that have no common meaning and are not recognized.

A nurse is conducting an initial assessment of a client. When the client enters the nurse's office, the client finds the nurse sitting with arms folded across the chest and an emotionless facial expression. The nurse is exhibiting which nonverbal communication technique? a. accepting body position and impassive face b. closed body position and impassive face c. accepting body position and expressive face d. closed body position and confusing face

b. closed body position and impassive face An impassive face is characterized by an emotionless, deadpan expression similar to a mask. The closed body position entails the nurse sitting with arms folded across the chest. Contrarily, an accepting body position would involve the nurse sitting with hands at the side of the body. This open posture demonstrates unconditional positive regard, trust, care and acceptance. An expressive face portrays the person's moment-by-moment thoughts, feelings, and needs. A confusing facial expression is one where the person is verbally expressing one emotion but showing a different one.

When educating a black client regarding newly prescribed antipsychotic medication, it is vital that the nurse address which care issue? a. keeping scheduled appointments with the health care provider b. early recognition of extrapyramidal symptoms c. taking the medication exactly as prescribed d. being aware of gastrointestinal side effects

b. early recognition of extrapyramidal symptoms Thirty-three percent of black clients have been found to be slower than white clients in metabolizing psychotropic medications. This decreased metabolism can lead to an increased incidence of adverse effects, especially extrapyramidal symptoms. Taking the medication exactly as prescribed, being aware of gastrointestinal side effects, and keeping scheduled appointments with the health care provider represent recommendations applicable to all clients prescribed a psychotropic medication.

A client has been prescribed clozapine for treatment of schizophrenia. The client must be taught to monitor which blood concentrations weekly while taking this drug? a. hematocrit b. white blood cells c. hemoglobin d. platelets

b. white blood cells Agranulocytosis can develop with the use of all antipsychotic drugs but it is most likely to develop with clozapine use. Clients taking clozapine should have regular blood tests. White blood cell and granulocyte counts should be measured before treatment is initiated and at least weekly or twice weekly after treatment begins.

A care plan states that a patient should attend groups on the unit, but the patient states, "I do not want to go; just let me sleep." What is the best response by the nurse? a. "You don't want to go?" b. "Ok, I will check back with you after a few hours." c. "I know you feel like staying in bed, but it is time for group. I will walk with you." d. "Oh, it will be fine. It is a glorious day."

c. "I know you feel like staying in bed, but it is time for group. I will walk with you." Diminished interest in almost all activities and fatigue are symptoms of major depressive disorder. Patients who are depressed may not want to participate in therapeutic activities and may have a difficult time functioning if their day is unstructured. The nurse should not be overly cheerful but should try to engage them and not just leave them in bed. Reflecting patients' feelings and encouraging them to attend will increase their activity, which will also have a positive effect on their social skills and enhance sleep. The nurse should avoid asking "yes or no" questions.

The patient states that the FBI is infusing laughing gas through the air vents. Which of the following is the nurse's best response? a. "Really, I had no idea; that is so interesting. I wonder how they do that." b. "You know that is not true; I have told you many times already." c. "I understand that you believe there is gas coming through the vents; come out to the day room and play a game." d. "No, we would not let that happen; come out to the day room and play a game"

c. "I understand that you believe there is gas coming through the vents; come out to the day room and play a game." When a patient is delusional, the providers should not argue with the patient, as it is an internal belief. It is not acceptable to play into the delusion but rather validate the feelings the patient has surrounding the delusion. The nurse can also encourage the patient to use distraction techniques, such as playing a game, listening to music, watching television, writing, or talking to friends

The patient is experiencing a delusion of grandeur and says, "I invented planes, do you ever fly, I did that, it was my patent." Which is the nurse's best response? a. "You know that was not you; remember, you worked in the baggage department." b. "Really? I had no idea. That is so interesting. Tell me about it." c. "I understand that you believe you invented planes." d. "No, you did not. I am not sure why you are so insistent."

c. "I understand that you believe you invented planes." When a patient expresses delusional thinking, the providers should not argue with the patient, as it is a fixed belief. It is not therapeutic to play into the delusion; rather, the nurse should validate the feelings the patient has surrounding the delusion.

When reviewing the discharge medications, Mr. Chen asks the nurse whether there are any specific instructions for administration of venlafaxine. What is the best response? a. "There are no special considerations with this medication." b. "You may skip the dose if you do not feel it is needed." c. "Take the medicine with food to decrease gastrointestinal upset." d. "Take venlafaxine at bedtime on an empty stomach."

c. "Take the medicine with food to decrease gastrointestinal upset." Venlafaxine is administered with food to decrease gastrointestinal upset.

Mr. Carter tells the nurse, "That is not nice. I can tell you are listening to my thoughts." Which statement is the best response from the nurse? a. "I am not sure what you mean. Can you elaborate?" b. "No, I cannot hear your thoughts." c. "That is frightening. Consider taking your as-needed medication." d. "I am sorry you feel that way. Thought insertion is scary."

c. "That is frightening. Consider taking your as-needed medication." Thought broadcasting is when a patient believes someone can hear his or her thoughts. This positive symptom can be regulated with antipsychotic medication.

Mr. Carter's family is concerned about his psychosis and are uncertain as to his future. They ask the nurse whether they should attend therapy sessions with Mr. Carter. Which is the best response from the nurse? a. "Often the copayments are a financial burden. I suggest checking first." b. "The therapist will work with Mr. Carter first and let you know whether you should be included in the sessions." c. "Therapy can aid you in understanding the disorder and to plan for what is ahead of all of you." d. "Do you think it would be helpful?"

c. "Therapy can aid you in understanding the disorder and to plan for what is ahead of all of you." Therapy for both the patient and the family is essential in defining social skills, helping them understand the pathology of symptoms, aiding in recovery, and helping prevent readmissions.

Which of the following is a negative schizophrenia symptom? a. Echopraxia b. Auditory hallucinations c. Alogia d. Disorganized behavior

c. Alogia Alogia (poverty of content) is a negative symptom, which cannot be controlled by medication. This symptom occurs when the patient cannot make a complete thought and the speech does not make sense. Auditory hallucinations (false auditory perceptions), echopraxia (imitation of the movements and gestures of another person), and disorganized behavior (outlandish appearance or seemingly purposeless movements) are all considered positive symptoms of schizophrenia.

Mrs. Chen has been taking sertraline and venlafaxine for several days. This morning she is smiling and engaging in conversation. During the conversation she tells the nurse, "I am feeling relieved." What is the nurse's priority assessment? a. Ensure the patient continues to attend groups. b. Monitor the patient's intake and output. c. Assess the patient for suicidality and place her on closer observation. d. Assess the patient's vital signs.

c. Assess the patient for suicidality and place her on closer observation. A client's mood often improves in response to antidepressant medication. When patients are suddenly feeling better, they may have the energy to carry out a plan to kill themselves. Closer observation is necessary to ensure safety. The patient's safety is more important than any other aspect being assessed.

A client is suspected of having anorexia nervosa and meets the diagnostic criteria for the disorder. When conducting the physical examination, which would be a probable finding from the assessment? a. Heat intolerance b. Hypertension c. Bradycardia d. Complaints of heartburn

c. Bradycardia Associated physical exam findings include cold intolerance, complaints of constipation and abdominal pain, hypotension, and bradycardia.

The nurse is caring for a mental health client who has developed difficulty with balance and muscle tone after a car accident that involved a head injury. Based on this information, what area of the brain was most likely injured in the accident? a. Brain stem b. Diencephalon c. Cerebellum d. Pons

c. Cerebellum The cerebellum coordinates the voluntary muscles and maintains balance and muscle tone. The diencephalon maintains homeostasis and controls the autonomic nervous system and the pituitary gland. The brain stem connects the cerebrum and diencephalon with the spinal cord. The pons helps regulate respiration.

Which is a significant obstacle in providing psychiatric care for clients who have somatic symptom illnesses? a. There are no known successful treatments for these disorders. b. Clients with these disorders find it difficult to go to a clinic setting. c. Clients are often unrecognized because clients receive treatment in different primary care offices, and care is often fragmented. d. Clients are often embarrassed about the number and extent of their physical complaints.

c. Clients are often unrecognized because clients receive treatment in different primary care offices, and care is often fragmented. Clients focus on physical symptoms as the primary problem. When physicians are unable to diagnose the cause, clients are often referred to other physicians for further physical assessment.

When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what in a client? a. Numbness and tingling in the extremities b. Full of energy c. Confusion d. Long-term memory impairment

c. Confusion After ECT treatment, the client may be mildly confused or briefly disoriented. He or she is very tired and often has a headache. The client will have some short-term memory impairment. Numbness and tingling in the extremities is not an expected symptom of ECT.

The nurse is studying the medical record of a client who reports blindness. The record indicates there is no ocular abnormality. The client doesn't seem upset by the blindness. What is the client's most likely diagnosis? a. Hypochondriasis b. Optic nerve dysfunction c. Conversion disorder d. Somatic symptom disorder

c. Conversion disorder The client has no ocular abnormality and isn't distressed by the situation. These findings indicate that the client may have conversion disorder. This involves unexplained, usually sudden deficits in sensory or motor function, such as blindness. Hypochondriasis is condition in which a client is preoccupied with possibly having a disorder or contracting a serious illness. Because all tests for blindness were negative, the client does not have any somatic dysfunction, such as optic nerve dysfunction. Somatic symptom disorder is a condition characterized by one or more physical symptoms that have no organic basis.

Which characteristic differentiates conversion disorder from malingering disorder? a. Conversion disorder is normally permanent, while malingering disorder is transient in response to stress. b. Conversion disorder produces reward, while malingering disorder normally results in punishment or difficulty. c. Conversion disorder is an unconscious process, while malingering disorder is a deliberate fabrication of symptoms. d. Conversion disorder has no pathophysiological cause, while malingering disorder has a neurological or endocrine basis.

c. Conversion disorder is an unconscious process, while malingering disorder is a deliberate fabrication of symptoms. In conversion disorder, anxiety-provoking impulses are converted unconsciously into functional symptoms. Malingering disorder is characterized by the voluntary production of false or grossly exaggerated physical or psychological symptoms. Both produce rewards, and neither has any pathophysiological cause. Neither disorder is considered a permanent or untreatable condition.

Which clinical manifestations confirm that a patient is experiencing Stage I (mild) of alcohol withdrawal syndrome? (Select all that apply.) a. Hypotension b. Disorientation c. Course hand tremors d. Diaphoresis e. Anxiety

c. Course hand tremors d. Diaphoresis e. Anxiety Stage I (mild) symptoms of alcohol withdrawal include coarse hand tremors, sweating, elevated pulse and blood pressure (not hypotension), insomnia, anxiety, and nausea or vomiting. Disorientation and confusion are associated with more severe and later stages of alcohol withdrawal.

What is the primary goal in working with an actively psychotic, suspicious patient? a. Promote interaction with others. b. Encourage participation in therapy activities. c. Decrease the patient's anxiety and increase trust. d. Improve the patient's relationship with his or her parents.

c. Decrease the patient's anxiety and increase trust. Patients who are paranoid, psychotic, and suspicious have a difficult time trusting others, especially caregivers. To increase the patient's compliance with medications and the treatment regimen, the nurse's priority is to establish trust. It is more important for the nurse to establish trust with the patient than to promote interaction with others or to try to improve the patient's relationship with his or her parents, because these last two interventions are not likely to improve compliance (although they will improve the patient's social skills and relationships).

A client who has been taking paroxetine for 3 years for depression abruptly discontinues the drug. For which signs and symptoms should the nurse monitor the client? a. Tardive dyskinesia and muscle rigidity b. Tachycardia and urinary retention c. Diarrhea and agitation d. Nightmares and paradoxical agitation

c. Diarrhea and agitation When a client who has been taking paroxetine for 3 years for depression abruptly discontinues the drug, the psychiatric nurse assesses him frequently for diarrhea and agitation. The signs and symptoms identified in the remaining options are not associated with withdrawal from the abrupt discontinuation of paroxetine.

A 22-year-old patient has been newly diagnosed with schizophrenia without hallucinations. Which task does the nurse realize is most critical to complete during the admission? a. Notify the patient's school of the diagnosis. b. Educate family members of a possible increased risk for homicidal tendencies. c. Educate the patient on the importance of medication adherence. d. Reassure family members of the low risk of suicide attempt.

c. Educate the patient on the importance of medication adherence. Educating the patient about the medications can help prevent a relapse. This is important because with each relapse and subsequent hospitalization, outcomes become increasingly difficult to maintain. Notifying the patient's school of the diagnosis is a much lower priority intervention. Emphasizing medication adherence will do more to reduce the risk of suicidal and homicidal tendencies than will simply educating the family about these risks.

Which verbal cue refers to accents on words or phrases that highlight the subject or give insight on the topic? a. Pitch b. Tone c. Emphasis d. Intensity

c. Emphasis Emphasis refers to accents on words or phrases that highlight the subject or give insight on the topic. Tone can indicate whether someone is relaxed, agitated, or bored. Pitch carries from shrill and high to low and threatening. Intensity is the power, severity, and strength behind the words.

Which statement regarding gender and suicide is correct? a. Females are more likely than males to die from suicide. b. Females are more likely to die by firearm than males. c. Females engage in suicidal behaviors more frequently than males. d. Females choose more violent means of suicide than males.

c. Females engage in suicidal behaviors more frequently than males. While females engage in suicidal behaviors approximately three times more frequently than males, males are at least four times more likely to die from suicide. This outcome may be because men generally tend to choose more violent methods. In the United States, two thirds of male suicide victims die by firearm. The most common cause of death by suicide in women is overdose or poisoning.

A client with schizophrenia is hearing voices that tell the client to kill the self. What term is used to identify this type of false sensory perception? a. Ideas of reference b. Delusion c. Hallucination d. Flight of ideas

c. Hallucination A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

Mrs. Chen begins to plan her aftercare to prevent another hospitalization. The case manager offers a partial hospitalization program after discharge. What is the priority rationale for this intervention to prevent relapse? a. It is not encouraged with patients with major depression. b. It provides a therapeutic community where patients receive electroconvulsive therapy. c. It provides the patients with structure and additional teaching on coping strategies. d. It is used if the patient is no longer able to stay in the hospital.

c. It provides the patients with structure and additional teaching on coping strategies. Partial hospitalization programs provide structure for patients, especially those with repeated admissions who may need additional support and assessment. The primary rationale for a patient entering a partial hospitalization program after discharge is not because the patient is unable to stay in the hospital any longer or to receive electroconvulsive therapy.

A client from which cultural background would most likely have an older family member present when discussing health issues with the nurse? a. Italian b. Australian c. Korean d. French

c. Korean The nurse must understand the differences in how various cultures communicate. It helps to see how a person from another culture acts toward and speaks with others. Australia and many European cultures are individualistic; they value self-reliance and independence and focus on individual goals and achievements and so would be less likely to include others in the discussion. Other cultures, such as Chinese and Korean, are collectivistic, valuing the group and observing obligations that enhance the security of the group.

As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process? a. Neologisms b. Magical thinking c. Loose associations d. Ideas of reference

c. Loose associations In some cases a client presents several thoughts that don't make sense in conjunction with one another. This is often seen in clients with acute exacerbations of schizophrenia and is described as loose association.

A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the highest risk for a suicide attempt? a. Woman with acute stress disorder b. Man with bipolar I disorder c. Man with major depressive disorder d. Woman with somatoform disorder

c. Man with major depressive disorder Men have a higher suicide completion rate than women. For men, suicide is the eighth leading cause of death, with a rate of 17.5 per 100,000—more than four times the rate in women. White men complete 73% of all suicides; 80% of these deaths are by firearms. Men are more likely to use means that have a higher rate of success, such as firearms and hanging. Most suicide deaths occur in men with a psychiatric disorder, primarily depression, in many cases complicated by substance abuse.

Which best describes the concept of somatization? a. Physical symptoms that are all in one's head b. Psychological origin of illness that is not real c. Manifestation of physical symptoms from psychological distress d. Symptoms that cannot be substantiated by physicians

c. Manifestation of physical symptoms from psychological distress The concept of somatization acknowledges and respects that bodily sensations and functional changes are expressions of health and illness, and even though they may be unexplained, they are not imaginary or "all in the head." Somatization (from soma, meaning body) is the manifestation of psychological distress as physical symptoms, which may result in functional changes, somatic descriptions, or both. The terms hysteria and hysterical were used to describe physical or emotional symptoms that could not be substantiated by physicians.

A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention? a. Assessing for post-electroconvulsive therapy disorientation and confusion. b. Teaching the client to avoid foods with tyramine. c. Monitoring blood levels of the medication. d. Monitoring phototherapy response.

c. Monitoring blood levels of the medication. Lithium is the drug of choice for clients with bipolar illness and has a high antimanic effectiveness. Lithium decreases the intensity, frequency, and duration of manic and depressive episodes. Blood levels need to be monitored for therapeutic levels during the acute phase (1.0-1.5 mEq/L) and during longer term maintenance. Other treatments that could be expected for clients during mania include sedatives or antipsychotics. Electroconvulsive therapy, phototherapy, and monoamine oxidase inhibitors are not typically indicated during manic phases.

Which assessment finding confirms that a patient is experiencing moderate alcohol withdrawal? a. Total wakefulness b. Profuse sweating c. Nausea and vomiting d. Restless sleep

c. Nausea and vomiting Nausea accompanied by vomiting is associated with moderate or Stage II alcohol withdrawal. Restless sleep is observed in mild or Stage I withdrawal, whereas total wakefulness and profuse sweating are seen in the severe, Stage III withdrawal.

A client with a diagnosis of schizophrenia has been brought to the emergency department by a worker from the group home where the client resides. The worker states that the client has stopped taking medications and drank 2 to 3 gallons of water over the past several hours. What assessments should the nurse who is caring for this client prioritize? a. Blood glucose levels and body weight b. Assessing for allergic reactions, dry mouth, and lethargy c. Neurological assessment and monitoring of electrolyte levels d. Monitoring for evidence of hallucinations or delusions

c. Neurological assessment and monitoring of electrolyte levels Hyponatremia, electrolyte imbalances, and seizures may result from polydipsia. Consequently, close monitoring of the client's electrolytes and neurological status assessment are prioritized at this stage.

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline? a. Weight loss b. Excessive salivation c. Orthostatic hypotension d. Diarrhea

c. Orthostatic hypotension Side effects of amitriptyline include orthostatic hypotension, constipation, weight gain, and dry mouth.

During a report from the emergency department, the registered nurse is told the patient is of Asian descent. What will the registered nurse recognize when caring for this patient? a. Patients of Asian descent come alone to appointments. b. Patients of Asian descent hold firm eye contact. c. Patients of Asian descent may not need as high a dose of medications as others. d. Patients of Asian descent are cooperative and welcome psychotropic medications.

c. Patients of Asian descent may not need as high a dose of medications as others. Due to genetic composition, patients of Asian descent metabolize medications more slowly than others and therefore do not require as high a dose of psychotropic medications to produce a desired effect. The other answers are not necessarily more true of patients of Asian descent than of others.

The patient is being admitted to an inpatient psychiatric unit after an overdose in a suicide attempt. The patient is now medically stable. Which intervention should the registered nurse recognize as the priority action? a. Take the patient's vital signs and ensure he or she eats a meal. b. Record the patient's current medications. c. Place the patient on safety precautions. d. Complete the full admission history.

c. Place the patient on safety precautions. Maintaining the patient's safety is a priority, especially after an intentional overdose. Safety precautions are initiated to ensure the patient does not harm himself or herself. The other interventions should be performed after safety precautions are implemented.

Mr. Davis has been prescribed an oral benzodiazepine to assist in managing his withdrawal symptoms should his CIWA-Ar score rise to 8 or above. After a dose has been administered, what assessment result, directly related to the medication, would be a concern for the nurse? a. Patient reports a headache rated as a 3/5 b. Blood pressure of 154/90 mmHg c. Respiratory rate of 11 breaths/minute d. Patient reports ringing in his ears

c. Respiratory rate of 11 breaths/minute CNS depression is a side effect of benzodiazepines. A respiratory rate of 11 breaths/minute could indicate respiratory depression and thus should be a concern for the nurse. The blood pressure is baseline for this patient and a headache is a classic symptom of alcohol withdrawal. Tinnitus is not generally associated with an adverse reaction to a benzodiazepine.

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority? a. Hopelessness related to recent divorce b. Spiritual distress related to conflicting thoughts about suicide and sin c. Risk for suicide related to highly lethal plan d. Ineffective coping related to inadequate stress management

c. Risk for suicide related to highly lethal plan Safety is the priority. The overall goals for the client who is suicidal is first to keep the client safe and later to help him or her develop new coping skills that do not involve self-harm. Hopelessness related to recent divorce, ineffective coping related to inadequate stress management, and spiritual distress related to conflicting thoughts about suicide and sin would not be the priority diagnosis for this client.

The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform? a. Write the names of family members. b. Explain the perception of inkblot cards. c. Spell "America" backward. d. Interpret the meaning of a proverb.

c. Spell "America" backward. To assess the concentration of the client, the nurse should ask the client to spell "America" backward. This activity requires a good amount of concentration. Interpretation of a proverb or idiom is the task used to determine the use of abstract thinking by the client. Explaining the perception of inkblot cards is the Rorschach test and is useful to understand the coping styles, interpersonal attitudes, and characteristics of ideation of the client. Asking the client to write the names of family members is a task useful for assessing the memory of the client.

A nurse is with an adolescent who reports nothing to live for and wishing to be dead. Which nursing action would be the priority? a. Putting the client in seclusion with a staff member assigned to watch the client at all times b. Going to the client's psychiatrist to report the suicidal ideation c. Staying with the client to explore more of the client's thoughts about suicide d. Ascertaining the client's beliefs about what happens when you die

c. Staying with the client to explore more of the client's thoughts about suicide A true psychiatric emergency exists when an individual presents with one or more symptoms associated with imminent risk for suicidal behavior. The first priority is to provide for the client's safety while initiating the least restrictive care possible. Staying with the client and further exploring the client's thoughts about suicide will enhance safety and allow the nurse to more thoroughly understand the extent of the client's suicidal risk. It would not be appropriate to leave the client alone while the nurse goes to talk with the psychiatrist. Seclusion would be used only as a last resort because it is a highly restrictive environment. Determining the client's beliefs about death would be a topic to be addressed much later in the process.A true psychiatric emergency exists when an individual presents with one or more symptoms associated with imminent risk for suicidal behavior. The first priority is to provide for the client's safety while initiating the least restrictive care possible. Staying with the client and further exploring the client's thoughts about suicide will enhance safety and allow the nurse to more thoroughly understand the extent of the client's suicidal risk. It would not be appropriate to leave the client alone while the nurse goes to talk with the psychiatrist. Seclusion would be used only as a last resort because it is a highly restrictive environment. Determining the client's beliefs about death would be a topic to be addressed much later in the process.

A college student wakes up and notices a racing heart and dilated pupils. The student is scheduled to write an exam later that morning. Which system is responsible for this physiological response? a. Cardiovascular irregularity b. The release of dopamine c. Sympathetic nervous system d. Autonomic nervous system

c. Sympathetic nervous system The sympathetic nervous system is stimulated by physical or emotional stress, such as strenuous exercise or work, pain hemorrhage, intense emotions, and temperature extremes. The specific body responses include: increased arterial blood pressure and cardiac output and pupil dilation to aid vision. The autonomic nervous system affects the cardiovascular function to decrease heart rate responses. The patient does not suffer from a cardiac irregularity. The release of dopamine will not affect pupillary response.

When admitting a patient experiencing visual and auditory hallucinations, the nurse discovers the patient is from another culture. Given this information, what should be the priority of the nurse in the development of the nursing care plan? a. The nurse should ask the patient whether he or she minds not discussing previous cultural practices. b. The nurse does not need to consider a person's ethnic or cultural background, as that will not impact the nursing care plan. c. The nurse should ask the patient and family about the ethnic or cultural significance of the hallucinations. d. The nurse should ask the patient whether he or she can comply with treatment.

c. The nurse should ask the patient and family about the ethnic or cultural significance of the hallucinations. Ethnicity and culture shape our worldview and our beliefs about all aspects of life, including the experience and expression of symptoms. Hallucinations in some cultures are a way of life and need to be explored. Oftentimes a patient may state he or she is seeing Jesus and is not hallucinating. Cultural considerations and exploration are priority when designing an individualized plan of care.

Which class of medication is regularly prescribed to provide a gradual withdrawal from alcohol? a. Anticonvulsant b. Antidepressant c. Tranquilizer d. Stimulant

c. Tranquilizer Safe withdrawal is usually accomplished with the administration of benzodiazepines, a class of tranquilizer, to suppress the withdrawal symptoms. None of the other classes is used generally to manage the classic symptoms associated with alcohol withdrawal. Anticonvulsants are prescribed if seizure activity is a risk and an antidepressant may be appropriate in the alcohol rehabilitation phase of recovery. Stimulants are contraindicated during the hyperactive stages of alcohol withdrawal.

Which are nursing actions that support active listening? Select all that apply. a. Interrupt conversations to ask more questions b. Sit with arms and legs crossed c. Use reflective comments d. Use appropriate vocabulary e. Use a computer to write out observations

c. Use reflective comments d. Use appropriate vocabulary During the comprehensive assessment, the nurse needs to be a good, active listener. Using appropriate vocabulary, tolerating a child's anxious, angry or sad behavior, and use of reflective comments are useful listening skills.

The school nurse is evaluating a 16-year-old student who came to the office complaining of dizziness. The student is very thin and was pacing in the office while waiting to see the nurse. The nurse asks the student to step on the scale. The student asks if the student can go to the bathroom first to empty the student's bladder, stating, "That can make a big difference." The student's comment raises the nurse's suspicion that the student has ... a. eating disorder not otherwise specified. b. binge-eating disorder. c. anorexia nervosa. d. bulimia nervosa.

c. anorexia nervosa. Anorexia is characterized by a voluntary refusal to eat and typically a weight less than 85% of what is considered normal for height and age. Clients with anorexia have a distorted body image and, to the bewilderment of others, view their emaciated bodies as fat.

A group of nursing students is role playing situations to practice using therapeutic communication techniques. What would the students identify as verbal communication? a. gestures b. body language c. emotion underlying the words d. expressions

c. emotion underlying the words Verbal communication, which is principally achieved by spoken words, includes the underlying emotion, context, and connotation of what is actually said. Nonverbal communication includes gestures, expressions, and body language.

What behavior is likely a result of an adolescent's attempt to manage the effects of over-productive parenting? a. socially withdrawing b. compulsively washing his or her hands c. engaging in severe dieting d. I becoming sexually promiscuous

c. engaging in severe dieting Two essential tasks of adolescence are the struggle to develop autonomy and the establishment of a unique identity. Autonomy, or exerting control over oneself and the environment, may be difficult in families that are overprotective or in which enmeshment (lack of clear role boundaries) exists. Such families do not support members' efforts to gain independence, and teenagers may feel as though they have little or no control over their lives. They begin to control their eating through severe dieting and thus gain control over their weight. Losing weight becomes reinforcing: By continuing to lose, these clients exert control over one aspect of their lives. While the remaining options may demonstrative reactive behaviors, they are not generally associated with over-productive parenting.

Mr. Chen is worried that his children will be depressed and he will not recognize the signs. What is the best response from the nurse? a. "Children with depression become more social and engaged in activities." b. "Often children do not show signs of depression until they are at least 16." c. "Children will tell you when they feel sad." d. "Children may become more irritable and display a school phobia."

d. "Children may become more irritable and display a school phobia." Children may not experience and express the classic symptoms of depression described in adults. They are more likely to display anxiety, fear of separation, somatic symptoms, and irritability. Children do not necessarily tell their parents when they are feeling sad. Children with depression can show signs at any age. Children are more likely to become less social and disengaged when depressed.

A nursing instructor is teaching about different depressive disorders and identifies a need for further instruction when a student states what? a. "Dysthymic disorder can significantly affect a patient's functioning." b. "Dysthymic disorder is milder than major depression." c. "With dysthymic disorder, depressed mood exists for most days for at least 2 years." d. "Dysthymic disorder is less chronic than major depression."

d. "Dysthymic disorder is less chronic than major depression." Dysthymic disorder is milder but more chronic than major depression and is diagnosed when the depressed mood is present for most days for at least 2 years with two or more other symptoms present.

The nurse is working with a client with schizophrenia who has cognitive deficits. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast? a. "Why don't you stay here and I'll get your tray for you." b. "Stay right there and I'll get your clothes." c. "I'll expect you in the dining room in 20 minutes." d. "First, wash your face and brush your teeth. Then put your clothes on."

d. "First, wash your face and brush your teeth. Then put your clothes on." The client needs clear direction, with tasks broken into small steps, to begin to participate in the client's own self-care. The client, not the nurse, should perform the steps.

Mr. Carter has been prescribed olanzapine 10 mg by mouth daily prior to admission. He tells the nurse he will not "take that medication ever again." What is the most therapeutic response from the nurse? a. "Make sure you eat a meal before taking the medication." b. "It is proven to be the best medication for your diagnosis." c. "Just take the medication and let your doctor know if there is further weight gain." d. "Gaining weight can be frustrating. Let's consider some changes in your diet and exercise."

d. "Gaining weight can be frustrating. Let's consider some changes in your diet and exercise." Weight gain is a common side effect of atypical antipsychotics. Weight gain is both detrimental to the patient's health as well as frustrating to the patient. Many patients will abruptly stop the medication due to the weight gain. The most therapeutic response of the nurse at this point is to both acknowledge the patient's frustration with the weight gain and to take action to address it. Although the other answers may be true, none are therapeutic because they do not address the patient's frustration with the weight gain.

Mrs. Chen states "None of the medications have made me feel better at all, and I've been on them for several months. Is there another treatment that may be helpful?" What is the best response from the nurse? a. "You should give it more time; your body will get used to the medication." b. "Why not try another medication to augment what you are currently taking?" c. "These medications do not work unless there is a sleeping medication used, too." d. "Have you discussed electroconvulsive therapy with your provider?"

d. "Have you discussed electroconvulsive therapy with your provider?" Some people do not respond to antidepressant medication. Electroconvulsive therapy is used for refractory depression, in which numerous medication trials have not been effective. Although medications can sometimes require 4 to 6 weeks to take effect, additional medications typically will not be effective unless another symptom is being treated. The medications do not require being combined with a sleeping medication to work.

A client has repeatedly been physically abused by the spouse. The client asks the nurse whether to leave the spouse like the mother has demanded. The nurse responds most therapeutically when answering: a. "What do you think your spouse would do if you leave?" b. "Your mother doesn't have the right to demand that; it's your decision." c. "Your mother may be right; I'd consider what she is saying." d. "How would leaving your spouse make you feel?"

d. "How would leaving your spouse make you feel?" Exploring the client's thoughts about leaving the situation is the priority for the therapeutic communication to be effective in this case. With this response, the interaction remains client centered and goal directed. Giving advice may facilitate dependency, thus it is important to elicit the client's thoughts on the matter; encouraging problem solving and decision making by the client is more constructive than giving advice.

The nurse has been teaching a client about bulimia. Which statement by the client indicates that the education has been effective? a. "I know if I eat pasta, I'll binge." b. "I'll take my medication when I feel the urge to binge." c. "How I feel about my body has little to do with my binging." d. "I'll eat small meals and snacks regularly."

d. "I'll eat small meals and snacks regularly." Clients with bulimia need to normalize their eating patterns. Therefore, the statement about eating small meals and snacks regularly indicates understanding of the need to normalize eating patterns. Emotional and environmental cues, not specific foods, influence the eating patterns in bulimia. Medication, if prescribed, is taken regularly, not just when the client experiences the urge to binge. Body image dissatisfaction is an underlying factor associated with bulimia.

Which of the following explanations should the nurse give to Mr. Carter's family when asked the cause of schizophrenia? a. "It is caused by a problem with the immune system. Has David been checked for immune deficiencies?" b. "It is caused by a genetic defect; who in your family has already been diagnosed?" c. "It is caused by a depletion of serotonin and acetylcholine in the brain." d. "It is caused by a combination of factors, including genetics and neurotransmitters."

d. "It is caused by a combination of factors, including genetics and neurotransmitters." Schizophrenia is a complex disorder with no one specific cause. Its etiology is thought to involve an interaction of genetics, brain chemistry, and psychosocial and environmental factors.

David has been recently started on an antipsychotic medication. He asks the nurse whether the medication will cure his schizophrenia. Which is the best response by the nurse? a. "Yes, if you take the medication daily as prescribed, the schizophrenia will finally go away." b. "Yes, the medication will cure the symptoms and the disease, and you will only require psychotherapy." c. "Why do you ask? Are you wondering whether you should take the medications that are prescribed?" d. "No, the medication does not cure the disease, but it will help to control the symptoms you are having."

d. "No, the medication does not cure the disease, but it will help to control the symptoms you are having." Antipsychotic medications can help to control the symptoms if taken as prescribed and follow-up care is received. There is no overt cure for this disease. The nurse should answer the patient directly and not assume that the patient is trying to get out of taking the prescribed medications.

What request of the patient being assessed for possible alcohol withdrawal should the nurse make to determine the presence of tremors? a. "Please make a tight fist and hold it for 5 seconds." b. "Please touch your thumb to your little finger." c. "Please interlock the fingers of both hands." d. "Please extend your arms and spread your fingers apart."

d. "Please extend your arms and spread your fingers apart." The standard way to assess for tremors associated with alcohol withdrawal syndrome is to observe the patient with arms extended and fingers spread apart. None of the other options would be as effective in identifying the course and/or fine involuntary quivering movement associated with tremors.

Mr. Chen asks the nurse at discharge if his two children are at risk for developing major depression like their mother. Which is the best response by the nurse? a. "Unfortunately, there is no research to show the genetic link." b. "No, major depression is more associated with socioeconomic factors than genetic factors." c. "Yes, the children are both highly likely to develop major depression." d. "Possibly. Evidence shows a strong genetic link to depression, with children being at a higher risk if one parent is diagnosed."

d. "Possibly. Evidence shows a strong genetic link to depression, with children being at a higher risk if one parent is diagnosed." Research indicates that genetics is a strong risk factor for developing major depression. Children of parents who are diagnosed have a stronger likelihood of developing the disease during their lifetime. Genetics is a stronger risk factor for major depression than are socioeconomic factors. Although the children are at increased risk for developing major depression, they are not "highly likely" to develop it.

Which of the following is an example of overgeneralization? a. "I should not have taken those pills." b. "Are my children going to be ok?" c. "I should tell my husband if I feel suicidal." d. "The therapy will not work; it didn't last time."

d. "The therapy will not work; it didn't last time." Overgeneralization is a cognitive distortion (thinking error) in which the patient assumes that because she had a negative experience with the first therapist, she will have negative experiences with all therapists. She is overgeneralizing (i.e., making a general statement about therapy based on too limited experience). The other responses express normal and accurate thoughts.

When teaching a class of nursing students about brief psychotic disorder, the instructor explains that the episode lasts for at least 1 day but less than which time frame? a. 1 week b. 1 year c. 6 months d. 1 month

d. 1 month In brief psychotic disorder, the length of the episode is at least 1 day but less than 1 month.

A nurse monitoring client medication needs to recognize side effects quickly and intervene promptly for which reason? a. Provide support to the client and let the client know this is normal b. Provide support to the client and encourage adherence as past side effects rarely reoccur c. Determine adequate dosage is maintained to control symptoms d. Alleviate the side effects and help client maintain adherence

d. Alleviate the side effects and help client maintain adherence Recognizing a medication's side effects quickly and intervening promptly to alleviate them will help maintain adherence.

Which medication classification blocks serotonin reuptake? a. Antibiotic b. Antimanic c. Antianxiety d. Antidepressant

d. Antidepressant The medication classification, selective serotonin reuptake inhibitors, blocks the reuptake of serotonin. Antianxiety, antibiotic, and antimanic medications do not block the reuptake of serotonin.

Mr. Carter is in the day room rapidly pacing, his fists clenched and mumbling angrily to himself. What is the nurse's priority intervention? a. Ask Mr. Carter if he wants to discuss why he is angry. b. Tell Mr. Carter he needs to calm down or he will be placed in seclusion. c. Ask Mr. Carter to go into his room. d. Ask the other patients in the day room to leave.

d. Ask the other patients in the day room to leave. Patients who are agitated—as evidenced by pacing, clenched fists, and self-dialogue—may become unpredictable. Safety is the top priority. The nurse should encourage the patient to calm down and offer an as-needed medication; seclusion and restraints are interventions of last resort. Clearing the room of other patients is a priority to ensure safety on the unit for all the patients.

The provider suggests changing Mrs. Chen's medication to phenelzine. Mrs. Chen says to the nurse, "The provider says I will need to watch my diet if I take a new medication; I am not sure I want to do this. Which foods would I have to avoid?" Which foods should the nurse mention? a. Black beans, garlic, pears b. Pork, shellfish, egg yolks c. Milk, kale, tomatoes d. Blue cheese, beer, pepperoni

d. Blue cheese, beer, pepperoni Patients who are prescribed monoamine oxidase inhibitors are urged to stay away from foods containing tyramine, which can cause a hypertensive crisis. Tyramine is an amino acid naturally found in small amounts in protein-containing foods such as strong or aged cheeses; cured, smoked, or processed meats; pickled or fermented foods; soybeans and soy products; and dried or overripe fruits. Monoamine oxidase inhibitors block the breakdown of tyramine and may cause a hypertensive crisis, which can be life threatening. The other answers are of lower priority because they are less likely to be life-threatening. The other foods listed do not contain tyramine.

Mr. Carter refuses to take his medication. He yells and throws the medicine cup containing his medications on the floor. What is the nurse's priority intervention? a. Approach Mr. Carter and tell him to pick up the items immediately. b. Restrain Mr. Carter with the help of others and forcibly administer his medication. c. Ask Mr. Carter if he wants to discuss why he is so mad. d. Call for help to ensure the safety of the staff, Mr. Carter, and other patients.

d. Call for help to ensure the safety of the staff, Mr. Carter, and other patients. Safety is the first priority, and calling for help will aid the patient and keep everyone safe. Patients are permitted to refuse medication, and use of restraints is a last resort. Although the nurse should speak with Mr. Carter later and ask why he was throwing items, now is not the time to do so. Although the patient's behavior may be threatening to the nurse, the patient is also feeling unsafe and may believe his or her well-being to be in jeopardy. Therefore, the nurse must approach the patient in a nonthreatening manner. Making demands or being authoritative only increases the patient's fears. Giving the patient ample personal space usually enhances his or her sense of security.

A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which would the nurse expect to implement in conjunction with pharmacologic therapy? a. Behavioral therapy b. Interpersonal therapy c. Family therapy d. Cognitive behavioral therapy

d. Cognitive behavioral therapy Although behavioral, interpersonal, and family therapy may be used, the combination of cognitive behavioral therapy and pharmacologic interventions is best for producing an initial decrease in symptoms.

A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed? a. Ask another nurse to attempt the assessment. b. Wait for psychiatric medication to take effect. c. Use observation only to collect client information. d. Complete the assessment in several short interactions.

d. Complete the assessment in several short interactions. Clients exhibiting psychotic thought processes or impaired cognition may have an insufficient attention span or may be unable to comprehend the questions being asked. The nurse may need several contacts with such clients to complete the assessment. Observing the client is a very important aspect of the assessment, however, it is not the only part. The nurse must interact with the client and engage in verbal communication in order to complete a full assessment. Psychiatric medication can take a period of time to have an effect. The assessment should be completed in a timely manner. In addition, understanding how a client presents when in a psychotic state can assist in planning for future acute psychiatric presentations. It is within each nurse's scope to complete the assessment. The nurse has not been ineffective in this case, the client's condition at the present moment is not favorable for conducting the assessment all at once.

Which term is used to refer to signals that encourage effective communication? a. Concrete messages b. Metaphors c. Abstract messages d. Cues

d. Cues A cue is a verbal or nonverbal message that signals key words or issues for the client. An abstract message is an unclear pattern of words that often contains figures of speech that are difficult to interpret. In a concrete message, words are explicit and need no interpretation. A metaphor is a phrase that describes an object or situation by comparing it to something else familiar.

The nurse working with pediatric clients knows the importance of checking for developmental delays, which not only slow the child's progress but also are often associated with what? a. Bullying b. Resilience c. Normalization d. Development of poor self-esteem

d. Development of poor self-esteem Developmental delays not only slow a child's progress but also can interfere with the development of positive self-esteem.

Which disease process is influenced by stress and emotions? a. Hypotension b. Bipolar disorder c. Deep vein thrombosis d. Diabetes

d. Diabetes Diabetes can be influenced by stress and emotions, as can other conditions such as hypertension and colitis. Deep vein thrombosis, biopoal disorder, and hypotension are not psychosomatic conditions.

A psychiatric-mental health nurse working in the community is planning an educational program for fifth- and sixth-grade teachers. Which would the nurse include? a. Stressing the need to allow students to eat without undue attention or supervision in order to prevent inadvertently influencing eating patterns b. Clarification that peer pressure is not typically problematic in children who are in the fifth and sixth grades c. Emphasis on the need for teachers to focus their prevention efforts on female students d. Discussion of strategies the teachers can use to counteract the role media plays in encouraging eating disorders

d. Discussion of strategies the teachers can use to counteract the role media plays in encouraging eating disorders Counteracting the influence of media should be stressed; both boys and girls are at risk for developing eating disorders. Other preventive educational strategies include the need to improve self-esteem and the importance of the influence of peer pressure on eating and weight.

Mr. Chen asks the provider about additional treatments to consider if his wife relapses. The provider tells Mr. Chen that electroconvulsive therapy (ECT) may be an option if the new medication does not help Mrs. Chen manage her depression. Which of the following is part of teaching for a patient considering ECT? a. ECT does not affect short-term memory the afternoon after ECT. b. ECT is only performed if the patient is not suicidal. c. ECT is no longer being used as a treatment for major depression. d. ECT is a treatment that requires conscious sedation.

d. ECT is a treatment that requires conscious sedation. ECT requires the patient to be NPO due to risk of aspiration with sedation. The patient is given sedation in a controlled environment.

What is the priority nursing intervention before Mrs. Chen leaves to go home? a. Ensuring she has a ride, because she cannot drive while on medication b. Ensuring that her insurance information is up to date c. Ensuring she has eaten a meal in case her family is not home d. Ensuring she is safe by asking if she feels suicidal

d. Ensuring she is safe by asking if she feels suicidal Safety is the first priority even at discharge. A patient with recurrent suicide attempts is at a higher risk for a repeat attempt. The patient can drive while on sertraline and venlafaxine. Ensuring that she has eaten a meal and that her insurance information is up to date is not as important as ensuring her safety.

What symptom of alcohol withdrawal syndrome would be the most urgent for the nurse to address? a. Insomnia b. Hallucinations c. Anxiety d. Grand mal seizures

d. Grand mal seizures Although all of the options may occur during alcohol withdrawal, grand mal seizures can be life-threatening and thus would be the most urgent for the nurse to address.

A young adult client is brought to the outpatient mental health clinic by the client's father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father reports the client continues to hear voices despite adhering to the medication. Which term best describes the client's abnormality of perception? a. Perseveration b. Fugue state c. Illusion d. Hallucination

d. Hallucination A hallucination is a subjective sensory perception in the absence of real external stimuli. The client can hear, see, smell, taste, or feel something that does not exist in reality. In this case, the client's sister died and cannot be speaking to the client, although in the client's mind the client can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.

Which statement about light therapy is true? a. Light therapy is not effective for any depressive diagnosis. b. It can be effective for major depression with manic episodes. c. It can be effective for severe major depression. d. It can be effective for mild-to-moderate seasonal depressive episodes.

d. It can be effective for mild-to-moderate seasonal depressive episodes. Light therapy (phototherapy) is used for mild-to-moderate seasonal depressive episodes. Evidence correlates light to enhanced moods; oftentimes in patients with a diagnosed bipolar disorder, the light enhances manic symptoms.

Mrs. Chen articulates that she has learned new coping strategies while at the hospital. The nurse recognizes that Mrs. Chen's statement indicates which outcome? a. Mrs. Chen is safe for discharge and will not relapse. b. Mrs. Chen is still intelligent. c. Mrs. Chen has gained social skills. d. Mrs. Chen realizes that coping strategies can prevent a relapse.

d. Mrs. Chen realizes that coping strategies can prevent a relapse. Coping strategies are taught and developed at the outset of acute hospitalization and are a means to prevent relapse in the event that stress overwhelms a patient. Mrs. Chen's learning of new coping strategies indicates that she understands their value in helping to prevent a relapse. Just because Mrs. Chen has gained new coping skills does not necessarily indicate that she has gained new social skills, is still intelligent, or is safe for discharge.

A client had been withdrawn in the client's room for 3 days, not eating or sleeping, prior to his admission to the inpatient unit. Upon interview, the client demonstrates difficulty answering questions, appears to have no facial expressions, and cannot follow simple instructions. This cluster of symptoms can be described as what? a. Delusions b. Thought disorder c. Positive symptoms d. Negative symptoms

d. Negative symptoms Common negative symptoms of schizophrenia include alogia, affective blunting, avolition, anhedonia, and attentional impairment.

A client with schizophrenia is receiving antipsychotic therapy. The nurse understands that which is a medical emergency should it develop in the client? a. Parkinsonism b. Akathisia c. Tardive dyskinesia d. Neuroleptic malignant syndrome

d. Neuroleptic malignant syndrome Although tardive dyskinesia, parkinsonism, and akathisia can occur with antipsychotic therapy, neuroleptic malignant syndrome is a life-threatening condition and medical emergency that requires immediate treatment.

Which factor is most likely to decrease the severity of Mr. Davis's alcohol withdrawal signs and symptoms? a. Being only 56 years of age b. Having been consuming vodka for only 5 years c. Having the emotional support of his strong religious faith and beliefs d. Never experiencing alcohol withdrawal signs and symptoms before

d. Never experiencing alcohol withdrawal signs and symptoms before Symptoms of alcohol withdrawal are typically more severe in older individuals and in those who have had previous alcohol withdrawal experiences. Although his age is a risk factor, Mr. Davis has had no previous withdrawal experiences, and this is a protective factor. Symptom severity is related more to quantity and type of alcohol consumed regularly than the length of the patient's drinking history. Mr. Davis's religious faith would be considered a protective factor in his recovery but has no relevance to the severity of his withdrawal.

A patient with a history of chronic alcohol abuse has begun to demonstrate signs and symptoms of delirium tremens (DTs). The nurse demonstrates an understanding of the seriousness of the patient's risk for injury when implementing which intervention? a. Orienting for time, place, and person as needed b. Restricting patient to the room c. Assessing for auditory and visual hallucinations frequently d. Observing seizure precautions

d. Observing seizure precautions Severe or untreated withdrawal may progress to DTs. Grand mal (tonic-clonic) seizures are a possible manifestation of DTs. Seizure precautions would be most appropriate to help in the management of this possible event. Although disorientation and hallucinations are possible, they do not pose the same degree of risk for injury as does a seizure. The patient doesn't benefit from being restricted to the room, but staff should closely monitor the patient.

The patient has overdosed on 50 tablets of nortriptyline. Which intervention is the priority action? a. Complete a mini mental exam. b. Take vital signs c. Complete the admission paperwork for transfer to an inpatient facility. d. Obtain an order for an electrocardiogram.

d. Obtain an order for an electrocardiogram. Tricyclic antidepressants, such as nortriptyline, can cause cardiac dysrhythmias and death in an overdose. Obtaining an electrocardiogram aids in the assessment of cardiac function. Although taking vital signs is important, assessment of cardiac rhythm with the possibility of cardiac arrest is the priority. The mini mental exam is for evaluating cognitive function in patients with dementia, and thus would not be appropriate to perform in this case. Transfer to an inpatient facility, if needed, would be a lower priority than conducting an electrocardiogram.

During a client interview, a client diagnosed with delusional disorder states, "I know my spouse is being unfaithful to me with a colleague from work."The nurse interprets the client's statements as suggesting which type of delusion? a. Grandiose b. Referential c. Sexual d. Persucatory/paranoid

d. Persucatory/paranoid The client's statements reflect persucatory/paranoid delusions that focus on the unfaithfulness or infidelity of a spouse or lover. Such delusions involve the belief that others are untrustworthy in some way. With referential delusions, the ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. In the sexual delusion subtype, ideas involve the belief that the client's sexual behavior is known to others. With grandiose delusions, individuals believe that they have a great, unrecognized talent or have made an important discovery.

The patient is at the window and states, "The voices are telling me to kill my roommate." Which is the priority nursing intervention? a. Offer the patient his or her as-needed medication. b. Tell the patient to lie down until he or she feels better. c. Ask the patient to explain what the voices are saying. d. Place the patient on one-to-one care for close observation.

d. Place the patient on one-to-one care for close observation. Command hallucinations, such as the one in this example, are a safety concern. In such cases, the patient should be placed on constant observation immediately and then offered as-needed medications. The nurse should not simply tell the patient to lie down, because this will not address the safety concerns associated with the command hallucination. Asking the patient to explain what the voices are saying is not necessary, as the patient has already indicated what they are saying.

Which would not be included as a purpose of the psychosocial assessment? a. Current emotional state b. Mental capacity c. Behavioral function d. Previous compliance with treatment regimen

d. Previous compliance with treatment regimen The previous amount of compliance with the treatment regimen would not be included as a purpose of the psychosocial assessment. Current emotional state, behavioral function, and mental capacity are included in the psychosocial assessment.

The nurse is caring for a patient newly diagnosed with schizophrenia. When developing the plan of care, what is the priority for developing interventions? Recognition that symptoms vary for each patient a. Recognition that the patient will likely have to be institutionalized b. Recognition that with therapeutic counseling, the patient will likely be able to hold down a job c. Recognition that there is no medication that will help the patient's symptoms d. Recognition that symptoms vary for each patient

d. Recognition that symptoms vary for each patient Schizophrenia is a known syndrome with multiple varieties and symptoms, making individualized care essential. Historically, these patients were institutionalized due to their bizarre presentations. Thanks to the increased effectiveness of newer atypical antipsychotic drugs and advances in community-based treatment, many patients with schizophrenia live successfully in the community. Patients whose illness is medically supervised and whose treatment is maintained often continue to live and sometimes work in the community, with family and outside support. Therapeutic counseling alone is not likely to enable a patient with schizophrenia to live independently or hold down a job.

A 22-year-old male college student presents with an acute onset of disorganized thinking and auditory hallucinations, and states that he is Superman. The nurse recognizes that these symptoms most likely indicate which condition? a. Bipolar disorder b. Schizoaffective disorder c. Dementia d. Schizophrenia

d. Schizophrenia he symptoms indicated are most consistent with schizophrenia, which is characterized by delusions, hallucinations, and grossly disorganized thinking, speech, and behavior. Schizoaffective disorder is diagnosed when the patient is severely ill and has a mixture of psychotic and mood symptoms. The signs and symptoms include those of both schizophrenia and a mood disorder such as depression or bipolar disorder. The patient in this case, however, is not demonstrating any signs of depression or bipolar disorder. Dementia is a disease process marked by progressive cognitive impairment, particularly memory impairment, and is not associated with hallucinations or delusions; moreover, dementia is unlikely in a patient who is 22 years old.

Medications have been tried for somatic symptom disorder. Which drugs have been shown to be effective in some cases? a. Antianxiety agents b. Antihypertensive drugs c. Antipsychotics d. Selective serotonin reuptake inhibitors (SSRIs)

d. Selective serotonin reuptake inhibitors (SSRIs) SSRIs, given in sequential trials of one or more medications, have been found to be the drugs of choice for somatoform disorders; they are cost effective and helpful.

A client has been diagnosed with bulimia. Which cognitive behavioral technique would be useful for the client? a. Distraction b. Music therapy c. Guided imagery d. Self-monitoring

d. Self-monitoring Self-monitoring is a type of behavioral therapy. It is designed to help the client with bulimia. Guided imagery, distraction, and music therapy can be used to manage emotions, such as anxiety, by using relaxation techniques.

A client with command auditory hallucinations and a history of aggressive outbursts is observed pacing and grimacing while in the day room. Which should be the nurse's priority? a. Turn off the dayroom's television b. Ask the client why the client appears to be agitated c. Request that the other clients leave the dayroom d. Support the client in returning to the client's room

d. Support the client in returning to the client's room Removing the client from the milieu is the initial intervention that best addresses the safety of all the clients including the agitated client. The other provided options are not necessarily inappropriate, but none represents the best course of action.

The parents of a child with attention deficit hyperactivity disorder (ADHD) bring the child for a follow-up visit. During the visit, they tell the nurse that the child receives the first dose of methylphenidate at about 7:30 a.m. every morning before leaving for school. The teacher and school nurse have noticed a return in the child's overactivity and distractibility just before lunch. The child's second dose is scheduled for about 12 p.m. Which might the nurse suggest as a possible solution to control the child's symptoms a bit more effectively? a. Split the early morning dose in half. b. Give the second dose at 1 p.m. or later. c. Switch to another class of medication. d. Switch to a longer-acting preparation.

d. Switch to a longer-acting preparation. Methylphenidate has a total duration of action of about 4 hours. Thus, parents or teachers often describe a return of overactivity and distractibility as the first dose of medication wears off. This "rebound effect" can often be managed by moving the second dose of the day slightly closer to the first dose. Longer-acting preparations of methylphenidate or amphetamine-dextroamphetamine do not require frequent dosing and may be a better fit with a school day schedule. Splitting the dose in half would affect the duration. Switching to another class of medication would be appropriate if the drug was ineffective in controlling the symptoms even with a change in the dosage schedule or after a switch to a longer acting preparation.

A client is seen in an outpatient mental health clinic for complaints of involuntary tongue movement, blinking, and facial grimacing. This syndrome would be identified correctly as what? a. Dystonia b. Neuroleptic malignant syndrome c. Akathisia d. Tardive dyskinesia

d. Tardive dyskinesia The symptoms of tardive dyskinesia include involuntary movements of the tongue, facial and neck muscles, upper and lower extremities, and truncal musculature. Neuroleptic malignant syndrome is a potentially fatal reaction manifested by rigidity, high fever, and autonomic instability. Acute dystonia includes acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. Akathisia is reported by the client as an intense need to move about.

A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what? a. The client will discuss the cause of the fatigue. b. The client will identify factors that reduce activity tolerance. c. The client will differentiate between reality and fantasy. d. The client will demonstrate improved ability to express self.

d. The client will demonstrate improved ability to express self. An appropriate outcome would include demonstrating improved ability to express self.

Which statement about the etiology of somatic symptom disorder is accurate? a. Most clients with somatic symptom disorder also suffer from schizophrenia. b. The disorder is associated with substance abuse. c. The disorder is more common in adults with a history of child abuse. d. The exact etiology is unknown.

d. The exact etiology is unknown. The cause of somatic symptom disorder is unknown. There is general agreement that somatization has a biopsychosocial basis with the possibility of biological dysfunction common in depression and chronic fatigue syndrome. Child abuse, substance abuse, and schizophrenia are not linked to somatic symptom disorder.

A nurse was placed in charge of the pediatric care unit. Over a period of time it was discovered that most of the children on the unit experienced sudden cardiac arrest. Although the nurse went to great lengths to revive the children, most of these children died. On further investigation, it was found that the nurse had been injecting high doses of digoxin drug in the children, which caused the cardiac arrest. The nurse was arrested and found guilty. What would have been the most likely cause of the nurse's behavior? a. The nurse might have Munchausen's syndrome. b. The nurse might have conversion disorder. c. The nurse might have somatic symptom disorder. d. The nurse might have Munchausen's syndrome by proxy.

d. The nurse might have Munchausen's syndrome by proxy. Munchausen's syndrome by proxy is a condition in which a person inflicts illness or injury on someone else in order to gain attention from becoming a "hero" for saving the victim. In this case, the nurse tried to kill the children and then went to great lengths to revive them. This indicates that the nurse had Munchausen's syndrome by proxy. In conversion disorder, the client has sudden deficits in sensory or motor function due to an unexplained cause. In somatic symptom disorder, the client reports having one or more than one physical symptom without any underlying cause. In Munchausen's syndrome the client inflicts illness or injury on oneself in order to gain attention.

A client with schizophrenia is prescribed an antipsychotic medication. Which immediate side effects would the nurse include in the education plan for this medication? a. The potential for weight loss b. Risk for hypoprolactinemia c. Risk for hypertension d. The potential for sedation

d. The potential for sedation Sedation with antipsychotic medication will likely happen immediately after initiating the medication. The nurse should be sure to inform the client they he or she will experience this side effect readily. The other options are examples of side effects that are possible with longer term treatment using antipsychotic medications. Weight gain is commonly associated with many antipsychotic medications. The potential for weight loss with antipsychotic medication is not typically discussed with clients.

Assessment of genetic predisposition supports asking a client who is exhibiting symptoms of a delusional disorder what? a. If the client has complied with the treatment plan b. When the delusion first began c. If any family member shows symptoms of depression d. Whether any family members have been diagnosed with schizophrenia

d. Whether any family members have been diagnosed with schizophrenia Some studies have found that delusional disorders are more common among relatives of individuals with schizophrenia than would be expected by chance; thus, asking whether any family members have been diagnosed with schizophrenia could be helpful.

A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should ... a. provide distraction by organizing therapeutic recreation. b. organize a family meeting. c. encourage the client to identify and attend outpatient support groups. d. help the client to identify and explore other options.

d. help the client to identify and explore other options. A client who is seriously considering suicide is doing so because the client sees it as their only option. The nurse should directly, but empathically, challenge this view. This client's high level of suicidality would preclude referral to outpatient support groups. Distraction is often beneficial but does not serve to challenge the client's beliefs. Similarly, a family meeting may or may not challenge the client's belief that suicide is the only option.