Psych Exam 4
A 16-year-old client diagnosed with Schizophrenia experiences command hallucinations to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain, which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain, causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."
A
A client diagnosed with NCD has progressive memory loss, diminished cognitive functioning, verbal aggression, and is experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.
A
A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension
A
A client scheduled for ECT at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. Based on this observation, which is the most appropriate nursing action? A. The nurse notifies the client's physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room. C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the client's fluid intake to facilitate the digestive process.
A
A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. "Taking multiple medications may lead to adverse interactions or toxicity." B. "Age-related cognitive changes may lead to alterations in mental status." C. "Lack of rigorous exercise may lead to decreased cerebral blood flow." D. "Decreased social interaction may lead to profound isolation and psychosis."
A
A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will this cure Alzheimer's disease (AD)?" Which is the appropriate instructor reply? A. "Donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." B. "Donepezil (Aricept) encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." C. "Donepezil (Aricept) delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." D. "Donepezil (Aricept) encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."
A
Immediately after an initial ECT procedure, a client states, "I'm not hungry and just want to stay in bed and sleep." Based on this information, which is the most appropriate nursing intervention? A. Allow the client to remain in bed. B. Encourage the client to join the milieu to promote socialization. C. Obtain a physician's order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation.
A
When scheduling ECT, which client should the nurse prioritize? A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood who is exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder
A
The nurse recognizes that ECT would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply. A. Major depressive disorder B. Bipolar I disorder: Acute mania C. Schizoaffective disorder D. Obsessive-compulsive disorder (OCD) E. Body dysmorphic disorder
A,B,C
During a course of 12 ECT procedures, an anxious client diagnosed with MDD refuses to bathe or attend group therapy. The client reports some memory problems and says he has trouble figuring out what time of day it is. Which of the following nursing diagnoses should be assigned to this client? Select all that apply. A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss
A,B,C,E
Which of the following conditions place a client at risk for injury during ECT? Select all that apply. A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy
A,B,D
Which assessment results should the nurse evaluate and report to prepare a client for ECT? Select all that apply. A. Electrocardiographic (ECG) records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results
A,B,D,E
A client diagnosed with Schizophrenia tells the nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is the correct charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoia." D. "The client is verbalizing a word salad."
B
A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to SAMHSA, which dimension of recovery is supporting this client? A. Health B. Home C. Purpose D. Community
B
A client is scheduled for an initial ECT procedure. Which information will the nurse include when teaching about the potential side effects of ECT? A. "You may experience transient tangential thinking." B. "You may experience some memory deficit surrounding the ECT." C. "You may experience avolution for the remainder of the day." D. "You may experience a higher risk for subsequent seizures."
B
A client states, "My doctor has told me I am a candidate for ECT. Where will the treatment take place, and how much time would this entail?" Which nursing reply is best? A. "Clients typically receive ECT in their hospital room, daily for 1 month." B. "Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting." C. "Clients typically receive an unlimited number of treatments, in the hospital procedure room." D. "Clients typically receive two to three treatments, in either an outpatient or inpatient setting."
B
A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement indicates to the nurse that the client has a positive prognosis? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."
B
A nurse maintains a client's confidentiality, addresses the client appropriately, and does not discriminate based on gender, age, race, or religion. Which guiding principle of recovery has this nurse employed? A. Recovery is culturally based and influenced. B. Recovery is based on respect. C. Recovery involves individual, family, and community strengths and responsibility. D. Recovery is person-driven.
B
A nursing instructor is teaching about ECT. Which student statement indicates that learning has occurred? A. "During ECT, a state of euphoria is induced." B. "ECT induces a grand mal seizure." C. "During ECT, a state of catatonia is induced." D. "ECT induces a petit mal seizure."
B
A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? A. "The goal of recovery is improved health and wellness." B. "The goal of recovery is expedient, comprehensive behavioral change." C. "The goal of recovery is the ability to live a self-directed life." D. "The goal of recovery is the ability to reach full potential."
B
A nursing instructor is teaching about the guiding principles of the recovery model, as described by the Substance Abuse and Mental Health Services Administration (SAMHSA). Which student statement indicates that further teaching is needed? A. "Recovery occurs via many pathways." B. "Recovery emerges from strong religious affiliations." C. "Recovery is supported by peers and allies." D. "Recovery is culturally based and influenced."
B
A nursing student is observing an ECT procedure. The student notices a blood pressure cuff on the client's lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply? A. "The cuff has to be placed on the leg because both arms are used for IV fluids." B. "The cuff functions to prevent succinylcholine from reaching the foot." C. "The cuff position gives a more accurate blood pressure reading during the treatment." D. "The cuff is placed on the leg so that arms can easily be restrained during seizure."
B
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which is the priority nursing action to maintain this client's safety? A. Assess for medication noncompliance. B. Note escalating behaviors and intervene immediately. C. Interpret attempts at communication. D. Assess triggers for bizarre, inappropriate behaviors.
B
During an admission assessment, the nurse asks a client diagnosed with Schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur
B
When assessing a client with polysubstance abuse, the nurse recognizes withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)
B
Which is the priority focus of recovery models? A. Empowerment of the health-care team to bring their expertise to decision-making B. Empowerment of the client to make decisions related to individual health care C. Empowerment of the family system to provide supportive care D. Empowerment of the physician to provide appropriate treatments
B
Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli to prevent seizures. B. Assess aggressive behaviors to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the CNS. D. Teach the negative effects of alcohol on the body.
B
A client diagnosed with Schizoaffective Disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader
C
A client diagnosed with Schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. I don't hear any voices speaking." D. "The devil only talks to people who are receptive to his influence."
C
A client diagnosed with a NCD is exhibiting behavioral problems every day. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action should the nurse implement first? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.
C
A client experienced bradycardia during ECT. A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve? A. The client will verbalize an understanding of the need for moving slowly after treatment. B. The client will maintain an oxygen saturation level of 88 percent 1 hour after treatment. C. The client will continue adequate tissue perfusion 1 hour after treatment. D. The client will verbalize an understanding of common side effects of ECT.
C
A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition? A. Mania B. Delirium C. NCD D. Parkinsonism
C
A client is in the late stage of Alzheimer's disease. To address the client's symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.
C
A client who is learning about ECT asks a nurse, "Isn't this treatment dangerous?" Which is the most appropriate nursing reply? A. "ECT is not dangerous because there are no side effects. B. "There can be temporary paralysis, but full functioning returns within 3 hours of treatment." C. "You will have a thorough examination beforehand to ensure you can safely undergo ECT." D. "Transient ischemic attacks can occur but are rare."
C
A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T chlordiazepoxide (Librium) tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to chlordiazepoxide (Librium)
C
A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering ECT. Which client information would impact the feasibility of this treatment option? A. Because the client is extremely suicidal, ECT is an appropriate option. B. Because antidepressant medications have been ineffective, ECT is a good alternative. C. Because informed consent is required for ECT, cognitive deficits could preclude this option. D. Because of the client's cognitive deficits, a signed consent is waived.
C
A nurse on an inpatient unit helps a client understand the significance of treatments and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the Tidal Model of Recovery? A. Know that Change Is Constant B. Reveal Personal Wisdom C. Be Transparent D. Give the Gift of Time
C
A nursing instructor is teaching about the medications given prior to and during ECT. Which student statement indicates learning has occurred? A. "Atropine sulfate is administered to paralyze skeletal muscles during ECT." B. "Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration." C. "Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious." D. "Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure."
C
A recovering alcoholic relapses and drinks a glass of wine. The client presents in the ED experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse recognizes that the client's symptoms indicate which of the following? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine
C
After undergoing two of nine ECT procedures, a client states, "I can't even remember eating breakfast, so I want to stop the ECT." Which is the most appropriate nursing reply? A. "After you begin the course of treatments, you must complete all of them." B. "You'll need to talk with your doctor about what you're thinking." C. "It is within your right to discontinue the treatments, but let's talk about your concerns." D. "Memory loss is a rare side effect of the treatment. I don't think it should be a concern."
C
At what time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications
C
Parents ask the nurse how they should reply when their child, diagnosed with Schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."
C
The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the Clinical Institute Withdrawal Assessment scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation
C
A client diagnosed with NCD due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes that these symptoms indicate which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage
D
A client diagnosed with Vascular Dementia is discharged to home under the care of his wife. Which information causes the nurse to question the client's safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.
D
A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) Model should be employed, and what action reflects this step? A. Step 3: Triggers that cause distress or discomfort are listed. B. Step 4: Signs indicating relapse are identified and plans for responding are developed. C. Step 5: A specific plan to help with symptoms is formulated. D. Step 6: Following a client-designed plan, caregivers now become decision makers.
D
A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a client's ECT procedure. What is the rationale for administering this medication? A. Robinul decreases anxiety during the ECT procedure. B. Robinul induces an unconscious state to prevent pain during the ECT procedure. C. Robinul prevents severe muscle contractions during the ECT procedure. D. Robinul decreases secretions to prevent aspiration during the ECT procedure.
D
The nurse in the ED assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which should be the nurse's first action? A. Contact the parents. B. Administer oxygen. C. Open the crash cart. D. Administer naloxone (Narcan).
D
The nurse is assessing a client diagnosed with Schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference
D
Which situation presents an example of the basic concept of a recovery model? A. The client's family is encouraged to make decisions to facilitate discharge. B. A social worker, discovering the client's income, changes the client's discharge placement. C. A psychiatrist prescribes an antipsychotic drug based on observed symptoms. D. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.
D
Which position should the nurse place the client in immediately after ECT?
On his or her side to prevent aspiration
A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for ECT. During the course of ECT, a nurse should recognize the continued need for which critical intervention?
Suicide assessment must continue throughout the ECT course.
A nurse administers pure oxygen to a client during and after electroconvulsive therapy (ECT). What is the nurse's rationale for this procedure?
To prevent anoxia due to medication-induced paralysis of respiratory muscles
