Q: A nurse on the psychiatric unit is assigned to work with a male client who appears reclusive and distrustful of everyone. The nurse can help the client develop trust by:

Being prompt(ì ìí) for their scheduled meetings

Question 1

A nurse on the psychiatric unit is assigned to work with a male client who appears reclusive and distrustful of everyone. The nurse can help the client develop trust by:

Accepted Answer

Being prompt(ì ìí) for their scheduled meetings

Question 2

A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse\'s response?

Accepted Answer

A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.

Question 3

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks?

Accepted Answer

Fluphenazine

Question 4

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. The nurse\'s behavior reflects:

Accepted Answer

Countertransference

Question 5

Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered?

Accepted Answer

Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma

Question 6

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? (Select all that apply.)

Accepted Answer

Rigidity Tremors Bradykinesia

Question 7

A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug\'s administration the client has baseline:

Accepted Answer

Renal studies

Question 8

A person mowing a lawn is badly disfigured by the lawnmower blade. According to Erikson\'s theory, which age at the time of injury will be associated with the greatest risk of long-term psychological effects?

Accepted Answer

11 years  An 11-year-old child is generally in Erikson\'s stage of industry versus inferiority, which involves the mastery of skills; unfortunately, the child did not master the skill of lawnmowing.

Question 9

A health care provider refers a 52-year-old man to the mental health clinic. The history reveals that the man lost his wife to colon cancer 6 months ago and that since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests have had negative results. Recently the client stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client\'s preoccupation with the fear of having a serious disease?

Accepted Answer

Hypochondriac disorder

Question 10

A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all \"bad.\" Which defense is the client using when identifying the other clients thusly?

Accepted Answer

Splitting

Question 11

Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client\'s jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client\'s chart. What should the nurse administer?

Accepted Answer

Benztropine (Cogentin), 2 mg intramuscularly7

Question 12

The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is:

Accepted Answer

Lorazepam (Ativan)

Question 13

The way individuals cope with an unexpected hospitalization depends on many factors. However, the one that is most significant is:

Accepted Answer

Basic personality

Question 14

A 2Â½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.)

Accepted Answer

\"Every time I turn around the kid is falling over something.\" \"I can\'t understand it. He didn\'t have a problem using the stairs without my help before this.\"

Question 15

A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client?

Accepted Answer

Tardive dyskinesia  Tardive dyskinesia occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It is most often manifested by abnormal movements of the lips, tongue, and mouth.

Question 16

What should a nurse ensure when creating an environment that is conducive to psychological safety?

Accepted Answer

Realistic limits are set.

Question 17

A 17-year-old teenager is found to have leukemia. Which statements by the teenager reflect Piaget\'s cognitive processes associated with adolescence? (Select all that apply.)

Accepted Answer

\"I\'m going to do my best to fight this awful disease.\" \"Now I can\'t go to the prom because I have this stupid disease.\" \"This illness is serious, but with treatment I think I have a chance to get better.\"

Question 18

A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The health care provider prescribes alprazolam (Xanax) 0.25 mg for agitation. The nurse should administer this medication when the:

Accepted Answer

Client requests something to calm her

Question 19

How should a nurse characterize a sudden terrorist act that causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation?

Accepted Answer

Adventitious  An adventitious crisis is a crisis or disaster that is unplanned and accidental; its subcategories include national disasters and crimes of violence.

Question 20

The nurse should first discuss terminating the nurse-client relationship with a client during the:

Accepted Answer

Orientation phase, when a contract is established

Question 21

A client who is being treated in a mental health clinic is to be discharged after several months of therapy. The client anxiously tells the nurse, \"I don\'t know what I\'ll do when I can\'t see you anymore.\" The nurse determines that the client is:

Accepted Answer

Reacting to the planned discharge

Question 22

A parent whose daughter is killed in a school bus accident tearfully tells the nurse, \"My daughter was just getting over the chickenpox and didn\'t want to go to school, but I insisted that she go. It\'s my fault that she\'s dead.\" How should the nurse anticipate that perceiving a death as preventable will likely influence the grieving process?

Accepted Answer

Bereavement may be of greater intensity and duration.

Question 23

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors the central factors that influence development?

Accepted Answer

Interpersonal theory

Question 24

A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior?

Accepted Answer

Intellectualization

Question 25

A male long-distance jumper improves his distance by 3Â½ inches (7 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate?

Accepted Answer

Displacement

Question 26

A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the course of treatment?

Accepted Answer

Elimination of benzodiazepines for nighttime sedation

Question 27

A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse\'s questions factually in a soft voice with a composed manner. This behavior may indicate that the client:

Accepted Answer

Is controlling the expression of feelings

Question 28

A nurse is caring for clients with a variety of psychiatric illnesses. For which diagnoses is the establishment of a psychiatric advance directive (PAD) most beneficial? (Select all that apply.)

Accepted Answer

Bipolar disease Paranoid schizophrenia

Question 29

When having a conversation with a nurse, an older client states, \"I\'ve lived a good life. I don\'t want to die, but I accept it as a part of life.\" What developmental stage, according to Erikson, has the client completed?

Accepted Answer

Integrity

Question 30

A client\'s hands are raw and bloody from a ritual involving frequent handwashing. Which defense mechanism does the nurse identify?

Accepted Answer

Undoing

Question 31

Which tool is used to standardize and measure nursing treatments?

Accepted Answer

Nursing Interventions Classification (NIC)

Question 32

What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?

Accepted Answer

Channeling unacceptable impulses into socially approved behavior

Question 33

A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the nurse, \"Which of the medications will be the most helpful against the psychotic signs and symptoms?\" What response should the nurse give?

Accepted Answer

Ziprasidone (Geodon)  Ziprasidone (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin. Citalopram (Celexa) is a selective serotonin reuptake inhibitor antidepressant. Benztropine (Cogentin) is an anticholinergic. Acetaminophen with hydrocodone (Lortab) is an analgesic/opioid.

Question 34

Certain questions are applicable in determining nursing negligence. (Select all that apply.)

Accepted Answer

\"Was reasonable care provided?\" \"Was there a breach of nursing duty?\" \"Was there an act of omission that resulted in harm? \"Except for the nurse\'s action, would the injury have occurred?\"

Question 35

A client is extremely depressed, and the practitioner prescribes a tricyclic antidepressant, imipramine (Tofranil). The client asks the nurse what the medication will do. The nurse responds:

Accepted Answer

\"It will help increase your appetite and make you feel better.\"

Question 36

A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions?

Accepted Answer

Occipital headaches

Question 37

An 18 year-old woman is brought to the emergency department by her two roommates after being found unconscious in the bathroom. Laboratory tests are ordered. The nurse reviewing the findings notes that the urinalysis is positive for flunitrazepam (Rohypnol). The nurse knows that flunitrazepam is often used:

Accepted Answer

As a date rape drug

Question 38

A client with type 1 diabetes is found to have a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination?

Accepted Answer

Decreased control of the diabetes

Question 39

A nurse understands that when a client is a member of a different ethnic community it is important to:

Accepted Answer

Offer a therapeutic regimen compatible with the lifestyle of the family

Question 40

A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary?

Accepted Answer

Undoing Undoing is atonement for or an attempt to dissipate unacceptable acts or wishes.

Question 41

A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, \"Sometimes I forget to take the Cogentin.\" What should the nurse teach the client to do if this happens again?

Accepted Answer

Take a dose as soon as possible, up to 2 hours before the next dose.

Question 42

Survivors of a major earthquake are being interviewed on admission to the hospital. The nurse notes that they exhibit a flattened affect, make minimal eye contact, and speak in a monotone. These behaviors are indicative of the defense mechanism known as:

Accepted Answer

Isolation Isolation is the separation of thought or memory from feeling.

Question 43

Methylphenidate (Ritalin) is prescribed to treat a 7-year-old child\'s attention deficit-hyperactivity disorder (ADHD). The nurse understands that methylphenidate is used in the treatment of this disorder in children for its:

Accepted Answer

Paradoxical effect

Question 44

A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse evaluate first after receiving report?

Accepted Answer

The 53-year-old client should be evaluated first because of the severity of adaptations associated with lithium toxicity.

Question 45

A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client?

Accepted Answer

Mydriasis Mydriatic action causes dilated pupils, which can precipitate an acute attack of glaucoma, resulting in blindness.

Question 46

For which adverse effect should the nurse continually observe a client who is receiving valproic acid (Depakene)?

Accepted Answer

Yellow sclerae

Question 47

A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention?

Accepted Answer

Obtaining information about her perception of the incident

Question 48

The nurse explains to a nursing assistant that behavior usually is viewed and accepted as normal if it:

Accepted Answer

Fits within standards accepted by one\'s society

Question 49

A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurse\'s performance. What situation indicates that the nurse-client boundaries of the recently hired nurse are appropriate?

Accepted Answer

The nurse shares with the entire treatment team vital information the client disclosed in a private session.

Question 50

A nurse encourages a client to attend Alcoholics Anonymous (AA) meetings after discharge. What do self-help groups such as AA help their members do?

Accepted Answer

Foster changes in behavior

Question 51

A client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). Because of the client\'s profoundly depressed behavior, the nurse doubts that the client can provide informed consent. What should the nurse\'s initial intervention be?

Accepted Answer

Having the client verbalize her understanding and the outcomes of the procedure

Question 52

In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this is usually accomplished through the use of:

Accepted Answer

Defense mechanisms

Question 53

The parents of a toddler with recently diagnosed moderate cognitive impairment discuss their child\'s possibility of future independent function. What should the nurse conclude?

Accepted Answer

Denial is being used as a defense.

Question 54

A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do?

Accepted Answer

Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation Symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and can cause death.

Question 55

Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?

Accepted Answer

Administering chlordiazepoxide as indicated by the client\'s CIWA score

Question 56

A client with schizophrenia is started on an antipsychotic/neuroleptic medication. The nurse explains to a family member that this drug primarily is used to:

Accepted Answer

Make the client more receptive to psychotherapy

Question 57

A neuromuscular blocking agent is administered to a client before electroconvulsive therapy. At this time, the nurse should monitor the client for:

Accepted Answer

Respiratory difficulties

Question 58

When talking with a client who has been receiving Paroxetine (Paxil), the nurse determines that more clarification is needed when the client says:

Accepted Answer

\"I\'ve been on the medication for 8 days now, and I don\'t feel any better.\"

Question 59

An adolescent on the psychiatric unit has an angry outburst toward another client who cut in front of people standing in line to get their mail. Later the nurse conducts a one-on-one therapeutic session with the angry client. What is an appropriate short-term goal for the client to strive for?

Accepted Answer

Talking about the situation that precipitated the anger

Question 60

A client is admitted for treatment of obsessive-compulsive disorder that is interfering with activities of daily living. Which medication should the nurse anticipate the health care provider will prescribe?

Accepted Answer

Clomipramine (Anafranil) Clomipramine (Anafranil) potentiates the effects of serotonin (antiobsessional effect) and norepinephrine in the central nervous system; it diminishes obsessive-compulsive behaviors. Benztropine (Cogentin) is an antiparkinsonian agent, not an antianxiety agent. Amantadine (Symmetrel) is an antiparkinsonian agent, not an antianxiety agent. Diphenhydramine (Benadryl) is an antihistamine, not an antianxiety agent.

Question 61

A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents\' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, \"People like that need to be put away before they kill someone.\" The nurse concludes that the client is using:

Accepted Answer

Projection

Question 62

A client has become increasingly depressed, and the practitioner prescribes an antidepressant. After 20 days of therapy, the client returns to the clinic. The client appears relaxed and smiles at the nurse. The most significant conclusion that the nurse can draw from this behavior is that the client:

Accepted Answer

Is responding to the antidepressant therapy

Question 63

The mother of an 18-year-old man comes to the local mental health center. She is extremely upset because of her son\'s behavior since the young man returned from his freshman year at college. He takes his brother\'s clothing, comes in at all hours, and refuses to get a job. Sometimes he is happy and outgoing, but at other times he is withdrawn. The mother asks why her son is like this. While contemplating this situation, the nurse considers that adolescents are usually:

Accepted Answer

Impulsive and self-centered

Question 64

The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention?

Accepted Answer

Active participant

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