NU473 Week 2: Evolve Elsevier EAQ Mental Health Disorders and Addictions

Which approach to a staff nurse's drug abuse problem would be taken as an initial intervention? o Counseled by the staff psychiatrist o Fired from the job immediately o Referred to the employee assistance program o Required to make a "stop drug use" contract

o Referred to the employee assistance program · Referral to the employee assistance program is a nonpunitive approach that attempts to help the nurse as an individual and as a professional. Counseling by the staff psychiatrist may be necessary for long-term therapy but is not the initial approach. Dismissal from the job is a punitive nontherapeutic response that offers no chance for rehabilitation. For a person who has an addiction problem, a contract is insufficient to prevent drug abuse.

Which common clinical manifestation is expected during the initial stage of alcohol detoxification? o Nausea o Euphoria o Bradycardia o Hypotension

o Nausea · During the first stage of alcohol detoxification, nausea, anorexia, irritability, tachycardia, and hypertension are expected.

Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? o The client is obese and always tries different or extreme diets. o The client has near-ideal weight and behavior can seem normal. o The client has a distorted body image and thinks of self as fat. o The client is struggling with dependence versus independence.

o The client has near-ideal weight and behavior can seem normal. · Bulimic clients hide much of their bingeing and purging behaviors and, unlike clients with anorexia, may have near-ideal body weights. Clients with bulimia nervosa are usually not obese. Clients with anorexia are more likely to try extreme weight loss diets. Distorted body image and conflict of dependence versus independence are associated with both anorexic and bulimic clients.

A client who has schizophrenia sees a group of visitors sitting together and says, "I know they're talking about me." Which altered thought process is the client demonstrating? o Flight of ideas o Ideas of reference o Grandiose delusion o Thought broadcasting

o Ideas of reference · In ideas of reference, the client has a delusional belief that she or he is the focus of ordinary events. Flight of ideas is the rapid thinking and speaking seen in clients in a manic state. Grandiose delusions are irrational beliefs that overestimate one's ability or worth. Thought broadcasting is the delusional belief that others can read one's thoughts.

Which question would the nurse ask to determine a client's potential for injury because of sleep deprivation? Select all that apply. o "Do you operate heavy machinery at work?" o "What activities do you do in your spare time?" o "Do you feel the need to take naps during the day?" o "Does sleepiness affect your performance at work?" o "How many hours of sleep do you get every night?"

o "Do you operate heavy machinery at work?" o "Does sleepiness affect your performance at work?" · The nurse would ask about operating heavy machinery at work or whether sleepiness affects the client's ability to work. Sleep deprivation is unlikely to affect a client's hobbies and activities. Information on naps and knowing how many hours of sleep the client gets can help determine a client's sleep requirements, but this information would not determine potential for injury.

Which client statement is an example of a somatic delusion? o "I wear this coat all the time to keep them from x-raying my organs." o "The president of France and I will be announcing our engagement soon." o "My heart stopped beating 3 days ago, and now my lungs are rotting." o "The government is sending assassins to kill me because I know too much."

o "My heart stopped beating 3 days ago, and now my lungs are rotting." · A somatic delusion is a belief that the body is changing or behaving in an unusual way (heart stopping and lungs rotting). Control delusions center on the belief that others are attempting to control or affect the person ("x-raying my organs") in some manner. Erotomanic delusions are focused on the belief that another person, usually famous or otherwise unattainable, is romantically interested in the client. Persecutory delusions involve beliefs that one is being singled out for harm ("sending assassins to kill me").

Which statement by a client with schizophrenia alerts the nurse that immediate safety precautions would be taken for others? Select all that apply. o "The voice told me to punch the guy." o "I saw the bugs crawling on the walls." o "God spoke to me; we prayed together." o "I was speaking to the other person here." o "There was someone here who told me to leave."

o "The voice told me to punch the guy." o "There was someone here who told me to leave." · A command hallucination pushes a person to perform an action. These hallucinations can be dangerous, because they may direct a client to do harm to him- or herself or others. The presence of command hallucinations on assessment requires immediate intervention by the nurse. Seeing bugs crawling on the walls is a visual hallucination. A client with auditory hallucinations may claim to have spoken to God or to a person who is not present in the room.

Which assessment findings are associated with Wernicke encephalopathy? Select all that apply. o Altered gait o Confusion o Ocular motility abnormalities o Tremulousness (i.e., jitters or shakes) o "Pins and needles" in the lower extremities

o Altered gait o Confusion o Ocular motility abnormalities · Wernicke encephalopathy, a substance-induced persistent dementia, is caused by a prolonged deficiency of vitamin B1 (thiamine). Symptoms include altered gait, vestibular dysfunction, confusion, and ocular motility abnormalities. Sluggish reaction to light and unequal pupil size are also symptoms. Tremulousness is a classic symptom of alcohol withdrawal. A pins and needles sensation in the lower extremities is a sign of peripheral neuropathy. In the case of prolonged alcohol use, peripheral neuropathy is also related to thiamine deficiency.

Which behavior is characteristic of oppositional defiant disorder? o Difficulty with focus o Argues with adults o Lies to obtain favors o Initiates physical fights

o Argues with adults · Oppositional defiant disorder is a repeated pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, usually exhibited before 8 years of age. Children with attention-deficit/hyperactivity disorder are easily distracted and have difficulties sustaining focus on a task. Lying to obtain favors and initiating physical fights are associated with conduct disorder and reflect violations of social norms.

List suicidal behaviors in priority order, from highest risk to lowest risk. o Threats of suicide o Suicidal ideation o Attempts at suicide o Suicidal gestures

o Attempts at suicide o Suicidal gestures o Threats of suicide o Suicidal ideation · The greatest risk includes behaviors that result in a minor or major injury with a definite attempt to end life. Behaviors that result in some minor, nonlife-threatening injury indicate a lesser intent to commit suicide. Overt verbal or written threats of suicide, with no expression of a specific plan, puts the health care team on alert to observe for escalation. Suicidal ideation represents direct or indirect thoughts about suicide without a definite plan; it poses the least risk for suicide.

Which effect of cocaine contributes to substance dependence? o Eases pain and discomfort o Blurs reality of problems o Creates a dreamlike state o Decreases motor activity

o Blurs reality of problems · The addict tries to avoid stress and reality. The drug produces a blurring of these feelings to the point that the addict becomes dependent on it. The psychological effect is usually more important than relief of physical pain or discomfort. Large doses of opioids, not cocaine, can cause a dreamlike state. Cocaine can increase, not decrease, motor activity.

The nurse is developing a care plan for a client with severe generalized anxiety disorder. Which intervention would the nurse include to maintain safety? Select all that apply. o Providing individual counseling o Collaborating with all disciplines o Instructing on relaxation exercises o Delivering calm and consistent care o Maintaining a low-stimulation environment

o Delivering calm and consistent care o Maintaining a low-stimulation environment · Interventions that protect clients with anxiety and maintain safety include delivering calm, consistent care and maintaining a low-stimulation environment. Individual counseling, interprofessional collaboration, and relaxation techniques are treatments for generalized anxiety rather than safety measures.

Which clinical manifestations would the nurse assess for in a client experiencing marijuana withdrawal? Select all that apply. o Depression o Chills o Red eyes o Abdominal pain o Increased appetite

o Depression o Chills o Abdominal pain · The nurse would assess for depression, chills, and abdominal pain. Withdrawal from marijuana/cannabis is within 1 week of cessation and presents with a depressed mood, irritability, anger, aggression, and insomnia. Physical symptoms of marijuana withdrawal include at least one of the following: chills, abdominal pain, shakiness, sweating, fever, or headache. Red eyes and increased appetite occur with marijuana/cannabis intoxication, not withdrawal.

Which personality traits are exhibited in a client who has a diagnosis of borderline personality disorder? Select all that apply. o Engaging o Indecisive o Withdrawn o Manipulative o Perfectionistic

o Engaging o Manipulative · Clients with borderline personality disorders initially tend to be engaging and to establish intense relationships. They may be manipulative because they are opinionated and want people to conform to their agendas. These clients are often decisive and opinionated, have a pronounced intolerance for being alone, and are usually quite social. These clients are not perfectionists.

The care plan for a client with bulimia nervosa includes "observe client after meals"; however, the client managed to purge four times in the past week. Which action would the nurse use first? o Tell the client that all privileges are revoked until the purging stops. o Confine the client to his or her bedroom with one-on-one observation. o Evaluate the factors that are affecting the success of the intervention. o Talk to the staff members who failed to prevent the purging.

o Evaluate the factors that are affecting the success of the intervention. · Observing the client after meals is the only way to ascertain that the client does not engage in purging; however, when a straightforward intervention is not working, the nurse must evaluate factors that are interfering (e.g., staff shortage, client manipulating staff, design of environment prevents observation). Once the constraints are identified, the plan can be revised. Revoking privileges, one-on-one observation, or talking to staff members may be actions that the nurse uses after evaluating the barriers.

A client who is disheveled and agitated demands, "Do something to make these feelings stop!" Which clinical manifestation is the client most likely experiencing? o Feelings of panic o Suicidal tendencies o Manic hyperactivity o Generalized dissociation

o Feelings of panic · The client can no longer control or tolerate these overwhelming feelings of panic and is seeking help. With suicidal thoughts, clients tend to be quiet and contemplative. Additional assessment would be needed to determine if the client is expressing suicidal tendencies. Clients who are in the manic phase usually do not want the feelings to stop. In dissociative disorders, clients are unable to connect an emotional trauma to an event; thus they may be unable to identify or articulate specific feelings.

For a client who has many self-inflicted nonlethal injuries over the preceding month, which level of suicidal behavior is demonstrated? o Threats o Ideation o Gestures o Attempts

o Gestures · A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; no definitive intent or action is expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

Which characteristics are likely to be demonstrated by a client with a diagnosis of schizophrenia? Select all that apply. o Hallucinations o Low self-esteem o Concrete thinking o Apathy o Blunted affect o Intact reality testing

o Hallucinations o Low self-esteem o Concrete thinking o Apathy o Blunted affect · A person with this schizophrenia manifests positive symptoms (hallucinations), negative symptoms (apathy), and alterations in cognitive function (concrete thinking) and affect (blunted affect). Low self-esteem is associated with schizophrenia because these people often experience stigma and have difficulty fulfilling social roles. Reality testing is impaired.

Which action would the nurse implement for a client with somatic symptoms? Select all that apply. o Scheduling office visits once a year o Having the client direct all requests to the case manager o Reminding the client who is in charge of their care o Conducting a physical examination only when necessary o Explaining to the client that the symptoms are not real o Taking vital signs each time client complains of symptoms

o Having the client direct all requests to the case manager · Clients with somatic symptoms would be instructed to direct all requests to the case manager to reduce manipulation. Frequent, brief, and regular office visits are recommended for clients with somatic symptoms. It would be counterproductive to remind the client who is in charge of their care, as power struggles are not helpful. A physical examination would always be conducted. The nurse would never imply that a client's symptoms are not real; rather, the nurse would acknowledge that the psychogenic symptoms are real to the client. After physical complaints have been investigated, the nurse would avoid taking vital signs for each complaint because this further reinforces the somatization.

Which activities would be best for an autistic child? o Activities with loud, cheerful music o Large-group activities o Cooperative craft activities o His or her own self-stimulating activities

o His or her own self-stimulating activities · Autistic behavior turns inward. Autistic children do not respond to the environment; instead, they attempt to maintain emotional equilibrium by rubbing and manipulating themselves, and they display a compulsive need for behavioral repetition. Autistic children do seem to respond to music, but not necessarily loud, cheerful music. Large-group (or small-group) activities have little effect on the autistic child's response. Part of the autistic pattern is the inability to interact with others in the environment, regardless of the size of the group.

Which nursing intervention is most important for preventing injury to a client preparing to undergo electroconvulsive therapy (ECT) treatment? o Obtain baseline vital signs. o Evaluate swallowing ability. o Implement seizure precautions. o Determine use of benzodiazepines.

o Implement seizure precautions. · ECT therapy uses an electrical current to stimulate seizure activity. The nurse would implement seizure precautions to protect clients from injury. Baseline vital signs would be obtained to assess cardiac and respiratory function, but this action is not the priority for client safety. The nurse would need to evaluate a client's ability to swallow after, not before, the ECT. Benzodiazepines would be discontinued before the treatment, because these medications prevent the onset of seizures.

For a client with bipolar disorder in the manic phase, which signs and symptoms are expected? Select all that apply. o Irritability o Grandiosity o Pressured speech o Thought blocking o Psychomotor retardation

o Irritability o Grandiosity o Pressured speech · Irritability and emotional lability fluctuating between euphoria and anger are commonly associated with mania. An inflated self-esteem and delusions of grandeur represent mood-congruent psychotic features of mania; clients believe that they possess extraordinary talents, that they are famous, or that they know someone famous. They are extremely talkative, and their speech is rapid, with an urgent quality (pressured speech); they rapidly change subjects and have flight of ideas and racing thoughts. Thought blocking occurs most often with schizophrenia; the client loses the train of thinking and is unable to retrieve the previous thought. Psychomotor retardation is related to depression; clients with mania move fast, pace, fidget, and are rarely still.

For a client with bipolar I disorder, manic episode, which factor would be considered to meet rest and sleep needs? o Experiences few sleep pattern disturbances o Requires less sleep than the average person o Is easily stimulated, and this interferes with sleep o Needs to expend energy to be tired enough to sleep

o Is easily stimulated, and this interferes with sleep · Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased stimulation decreases activity. Sleep pattern disturbances characteristically occur because of psychomotor activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of their high activity level. Expending energy only increases the tendency to remain awake.

For a client with schizophrenia, which symptoms are classified as negative symptoms? Select all that apply. o Lack of energy o Anhedonia o Illogical speech o Ideas of reference o Agitated behavior

o Lack of energy · A lack of energy (anergy) and anhedonia (inability to experience pleasure) are negative symptoms associated with schizophrenia. Illogical speech and ideas of reference, (i.e., a person believes she or he is the object of environmental attention) are positive symptoms of schizophrenia. Agitated, hostile, angry, and violent behaviors are positive symptoms of schizophrenia.

Which interventions would the nurse include in the plan of care for a client with depression who is at risk for self-directed violence? Select all that apply. o Provide safe outlets for energy. o Make rounds every 15 minutes. o Assign a room next to the nurses' station. o Reduce stimulation by dimming the lights. o Promote the discussion of negative thoughts.

o Make rounds every 15 minutes. o Assign a room next to the nurses' station. · Appropriate safety interventions for a client who is at risk for or showing signs of potential intent to self-harm would include making rounds to check on the client every 15 minutes and assigning the client to a room next to the nurses' station to allow nursing staff to check on the client frequently. Agitated clients benefit from being provided a safe outlet for extra energy and minimized stimulation. The nurse would encourage a client who is at risk for other-directed violence, not self-directed violence, to discuss the negative thoughts.

Which characteristic would the nurse consider when attempting to assess the defense mechanisms of an older adult client with neurocognitive disorder due to vascular impairment? o Avoids use of any defense mechanisms o Uses one method of defense for every situation o Makes exaggerated use of old, familiar mechanisms o Attempts to develop new defense mechanisms for the current situation

o Makes exaggerated use of old, familiar mechanisms · The guideline to remember is that clients will make exaggerated use of old, familiar mechanisms. Clients with neurocognitive disorders try to use defense mechanisms that have worked in the past but use them in an exaggerated manner. The client will use defense mechanisms, but they may not be effective. The client with neurocognitive disorder is not capable of focusing on one defense mechanism all the time because of short-term memory loss. Because of brain cell destruction, clients are unable to develop new defense mechanisms.

Alcoholics Anonymous (AA) is a successful self-help group because it fulfills which basic human need? o Trust develops between members. o Growth occurs for the members. o Members experience acceptance. o Members gain a sense of independence.

o Members experience acceptance. · Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on trust, growth, and independence.

For a client who is diagnosed with bulimia nervosa, which intervention is the most important? o Watch for pilfering and hoarding of food. o Encourage eating meals in the public dining area. o Assess for mood swings after eating. o Observe for amount consumed and purging.

o Observe for amount consumed and purging. · Clients with bulimia will eat uncontrollably and then purge. With purging, there is a loss of electrolytes, and the acidity of the stomach contents causes erosion of the teeth and damage to the esophagus. Pilfering, hoarding of food, and mood swings may occur with bulimia, and these clients will eat in public and in private. The primary goal is to help the client eat regular, well-balanced meals and break the cycle of binge eating and purging.

Which clinical manifestations would the nurse expect when assessing a client with schizophrenia? Select all that apply. o Paranoid behaviors o Loose associations o Inappropriate affect o Feelings of depression o Flashbacks

o Paranoid behaviors o Loose associations o Inappropriate affect · The nurse would expect paranoid behaviors, loose associations, and inappropriate affect. Paranoid behaviors are associated with schizophrenia. Loose association is a characteristic related to the thought disorders in schizophrenia. The affect usually is inappropriate in schizophrenia. Depression is not characteristic of schizophrenia. Flashbacks are associated with post-traumatic stress disorder or with certain substances, not with schizophrenia.

Which safety intervention would the nurse include in a plan of care for a client with somatic disorder who reports loss of vision? Select all that apply. o Apply restraints. o Administer sedatives. o Put the call light within reach. o Orient the client to surroundings. o Use therapeutic communication.

o Put the call light within reach. o Orient the client to surroundings. · A client with a somatic disorder who reports being unable to see is at high risk for injury due to new surroundings. Therefore, the nurse would provide safety and security by placing the call light within reach and orienting the client to the surroundings. Restraints are used only as a last resort to manage combative behavior. Sedatives are not needed if the client is not anxious. Therapeutic communication would be used but is not specific to providing safety.

An older client with vascular dementia has difficulty following brief and simple directions. Which cognitive impairment is the client experiencing? o Receptive aphasia o Impaired judgment o Decreased attention span o Clouding of consciousness

o Receptive aphasia · Receptive aphasia interferes with interpreting and defining words, and this cognitive dysfunction creates difficulties in following directions. Following directions does not require skill in judgment or decision-making. Attention span may be decreased, but brief directions require a minimal attention span. Dementia does not cause a clouding of consciousness; delirium does.

Place the following statements in order of progression for anorexia nervosa, from first to last. o Self-esteem increases as weight is lost. o Secondary gains reinforce the anorectic client's behaviors. o Dieting is an attempt to maintain control. o Social attitudes and struggle for independence exert pressure. o The client views self as being fat even when emaciated.

o Social attitudes and struggle for independence exert pressure. o Dieting is an attempt to maintain control. o Self-esteem increases as weight is lost. o The client views self as being fat even when emaciated. o Secondary gains reinforce the anorectic client's behaviors. · Sociocultural (fashion, "superwoman" issues, and the diet and fitness industry), biological, psychological, and familial factors all influence the development of anorexia nervosa. Dieting, exercise, purging, and laxatives are used to lose weight, with the resulting primary gain of a feeling of control over one's life. As weight is lost, the individual feels a sense of accomplishment, and self-esteem increases. Secondary gains such as attention from parents and peers reinforce the behaviors associated with anorexia nervosa. Clients with anorexia will continue to think of themselves as fat, even if they are emaciated or experiencing other obvious physical maladies, such as lanugo, amenorrhea, or weakness.

Which intervention would the nurse use to prevent self-induced vomiting in a client admitted for anorexia nervosa? o Monitor telephone calls. o Stay in the bathroom with the client. o Provide structured meal times. o Establish normal eating patterns.

o Stay in the bathroom with the client. · To prevent self-induced vomiting, a staff member should always accompany a client with anorexia to the bathroom. Monitoring telephone calls will not prevent self-induced vomiting. Structured meal times and normal eating patterns would be inpatient therapy interventions but do not prevent self-induced vomiting.

A client with obsessive-compulsive disorder (OCD) begins to perform a ritual that involves several complex hand motions, but it is time for the client to go to group therapy. Which intervention is the best choice? o Tell the client to stop going to group until the ritual is controlled. o Instruct the client to perform the hand motions for the group. o Delay the start of the group session until after the ritual is finished. o Tell the client to join the group as soon as the ritual is completed.

o Tell the client to join the group as soon as the ritual is completed. · The purpose of the ritual is to decrease anxiety, so the best choice is to tell the client to join the group as soon as she or he can. This is not ideal; the group norms usually include punctuality. For subsequent sessions the nurse and client would negotiate time for the ritual that did not overlap with the group time. The nurse would not discontinue a therapy without consulting the health care provider and other members of the health care team. Performing the hand motions during the group would be disruptive and distracting to the other group members, and it is likely to increase embarrassment for the client with OCD. Delaying the start of the group is not fair or therapeutic for the other group members.

A client admitted for substance abuse detoxification displayed extreme anger toward his spouse. Based on the client documentation below, which conclusion can be drawn? o The nurse responded appropriately, because the client expressed his feelings and calmed down. o The nurse responded inappropriately, because the nurse had to spend 30 minutes with the client. o The nurse responded appropriately, because communication de-escalated the aggressive behavior. o The nurse responded inappropriately, because the threat of harm to the wife was unaddressed.

o The nurse responded inappropriately, because the threat of harm to the wife was unaddressed. · Threatening physical harm requires notification of the appropriate individuals about any viable threat. This documentation reflects the nurse's failure to follow through and report the threat. Expressing feelings and de-escalation are a desirable outcomes, and therapeutic communication is a vital tool in addressing the client's anger, but the major safety issue cannot be left unaddressed. Spending time to de-escalate anger is an appropriate use of the nurse's time.

Which characteristic is associated with an addictive personality? o Unable to give up drugs o Unconcerned with reality o Unable to delay gratification o Unaware of the dangers of addiction

o Unable to delay gratification · A person with an addictive personality is unable to delay gratification; drugs help blur reality and ease frustration. Giving up drugs is possible, but not easy; it requires a change in attitude and a deconditioning process. Users of drugs are concerned with reality, and their drug use is an attempt to blur reality. Intellectually these people may be aware of the dangers of drug addiction, but emotionally the benefits seem to outweigh the dangers.