Psych exam 1

1. The nurse identifies that a usually talkative patient is withdrawn. The best response on the part of the nurse would be
A. “You are very quiet today.”
B. “What is it that’s bothering you?”
C. “Tell me what you’re upset about.”
D. “Why are you so withdrawn today?”
1. A
The word best is a key word in the stem that sets a priority. Options B & C are equally plausible because they make the assumptions that the patient is upset or bothered. However, Option A identifies the behavior and provides an opportunity for the patient to verbalize further.
Option B is too direct; it may put the patient on the defensive and cut off communication. In addition, the patient may not have the insight to answer the question.
Option C—same objection as Option B.
Option D: “Why” questions are too direct and often patients do not have the insight to answer them. Also, this statement draws the conclusion that the patient is withdrawn, which may be inaccurate.
2. A patient who has isolated himself on the unit states, “When I have the opportunity, I am going to kill myself.” The best response on the part of the nurse would be
A. “You have a wonderful family. They need you.”
B. “Let’s explore the reasons you have for living.”
C. “You must feel overwhelmed to want to kill yourself.”
D. “Suicide does not solve problems. Tell me what is wrong.”
2. C
Open-ended statements identify feelings and invite further communication. The word best is the key word in the stem that sets a priority. Options A, B, & D deny the patient’s feelings. Option C is unique because it is the only option that addresses feelings.
3. A client’s spouse died about a week ago. When talking about their life together, she begins to cry. The best response would be to
A. Leave the patient alone to provide privacy.
B. Say, “Everything will get better as time passes.”
C. Encourage the client to obtain grief counseling.
D. Say, “This must be an extremely difficult time for you.”
3. D
This statement identifies feelings, focuses on the patient, and provides an opportunity for the patient to share feelings.
Option A: Leaving abandons the client at a time when emotional support may be beneficial. Abandonment is an ultimate form of denial.
Option B: This statement is false reassurance and denies the patient’s feelings.
Option C: This may eventually be done, but the patient needs immediate support.
4. A patient tells the nurse “The doctor just told me I have breast cancer” and then begins to cry. What is the best response by the nurse?
A. “Sometimes it helps to talk about it.”
B. “I hope things will get better by tomorrow.”
C. “Deep breathing may help you regain control.”
D. “Crying is good because it gets it out of your system.”
4. A
This response recognizes the patient’s behavior and provides an opportunity to verbalize thoughts, feelings, concerns, etc. Options B, C, & D all imply that everything will get better. These are Pollyanna-like responses that deny the patient’s feelings.
5. A patient asks for advice regarding a family problem. The most effective response by the nurse would be to
A. Explain that nurses are not allowed to give advice to patients.
B. Encourage the patient to ask the psychiatrist about the issue.
C. Encourage the patient to discuss his/her own thoughts about the possible solutions.
D. Offer an opinion after fully listening to the patient.
5. C
This response provides an opportunity for the patient to explore concerns and alternative solutions without others influencing the decision making.
Option A denies the patient’s concern, puts the focus on the nurse, & may cut off communication. Option B is “passing the buck.”
Option D: Offering opinions is inappropriate. Opinions involve judgments that are based on feelings and values that may be different from the patient’s.
6. A client diagnosed with a thought disorder (schizophrenia) is sitting in her room one evening. She states, “I can see and hear someone sticking out from underneath my bed at night; also, he’s telling me that I need to be killed.” The most therapeutic initial nursing response to this statement would be
A. “I don’t see or hear anything, but it sounds as though you are very frightened.”
B. “Just tell the man to go away.”
C. “There is no man under your bed. It’s time to go to the dining room.”
D. “You are perfectly safe here. Don’t worry about it.”
6. A
This response is honest and acknowledges the patient’s distress.
Option B feeds into the patient’s psychotic thinking. Option C sets up an argument. Option D trivializes the patient’s fears.
7. A client who has been forced into early retirement is admitted to the hospital with severe depression. The client states, “I feel useless and have nothing to do.” The best initial response by the nurse would be:
A. “Tell me what you would like to do.”
B. “Your illness is adding to your feelings.”
C. “Have you thought about volunteering?”
D. “You feel useless; tell me more about that.”
7. D
This open-ended response encourages further discussion and allows for an exploration of feelings.
A. This response ignores the client’s feelings expressed in the statement.
B. The depression is not adding to the feelings, the feelings more likely precede the depressive episode.
C. Same as answer 1.
1. A hospitalized patient is in the acute stage of mania. Which of the following is an appropriate goal for the nurse and the patient to work toward? The patient will:
A. Spend at least 30 minutes per hour watching TV in the activity room
B. Participate actively in the psychodrama group each day.
C. Lead other patients in group physical exercises each morning.
D. Maintain distance of 2 to 3 feet at all times when interacting with others.
1. Correct Answer: Option D. The patient in a manic state is generally intrusive and insensitive to the needs of others and does not recognize boundaries, whether psychologic or physical. The patient also tends to have an intense preoccupation with sexual urges and frequently touches others or positions self in socially inappropriate ways. The nurse must encourage the client to set and maintain boundaries while interacting with others. The person in a manic state is unlikely to be able to conform to the schedule in option A or to sustain attention for this period of time. Additionally, the patient is likely to find the activity room more stimulating than a quieter area of the unit. Individuals experiencing manic affect tend toward overreaction and overdramatization in any situation, so participating in such a group would likely increase the patient’s manic hyperactivity and dramatization (Option B). While physical exercising will allow the patient to sublimate some of the excessive energy that is felt (Option C), the patient is likely to be domineering. Further, it is likely that the individual’s level of mania will increase because of the extra stimulation.
2. The nurse needs to teach a patient about newly prescribed sertraline (Zoloft). Which information is essential to include in the teaching? (Select all that apply).
A. Sertraline is most often taken as a morning dose.
B. Fever and flulike symptoms are bothersome but not dangerous side effects of sertraline.
C. Patients taking sertraline will usually recognize improvement within one week.
D. It is possible that sexual side effects will occur.
2. Correct Answers: Options A & D. The nurse should know that one of the common side effects of sertraline (Zoloft) is insomnia. Therefore, most patients are given sertraline (Zoloft) early in the day. Sexual side effects to sertraline (Zoloft) and the other SSRIs are common. One way to decrease the likelihood of noncompliance is to inform the patient that prompt reporting of such side effects can lead to corrective treatment measures. It is vital for the nurse to know that all persons taking sertraline (Zoloft) or other SSRIs should be taught to recognize early symptoms of possible central serotonin syndrome (Option B). Such symptoms include sudden onset fever, sweating, and extrapyramidal side effects (EPS). The development of central serotonin syndrome is a rare medical emergency, but the client will need intensive medical treatment because the mortality rate is very high. The nurse should teach the patient that while some reduction in symptoms may occur in a relatively short period, it might be several weeks before full therapeutic effects are realized (Option C). Without this knowledge, patients often become discouraged and think that the medication is ineffective.
3. A patient diagnosed with dysthymic disorder asks the nurse to explain what the diagnosis means. When responding to the patient, the nurse should state that before dysthymia can be diagnosed, depressed mood needs to be present for at least:
A. 2 weeks.
B. 4 weeks.
C. 1 year.
D. 2 years.
3. Correct Answer: Option D. According to the DSM V, dysthymic disorder cannot be fully diagnosed until the depressed mood has been present for at least 2 years. Additional criteria are specified to diagnose dysthymic disorder, and once the depressed mood criterion has been met, only some or the other criteria must be met. This is in contrast to the DSM V criteria for diagnosing major depression. In this case, at least 5 of 9 criteria must be met.
4. The nurse is conducting discharge teaching for a client taking tranylcypromine (Parnate). The nurse determines that the client understands the instructions given if the client says, “While I take this medicine, I should not eat:
A. Potatoes.”
B. Salami.”
C. Baked chicken.”
D. Cottage cheese.”
4. Correct Answer: Option B. Salami is a cured meat and must be avoided by patients taking tranylcypromamine (Parnate). Foods high in tyramine or tryptophan, such as cured foods, may induce a hypertensive episode in patients taking MAOI medication. Other foods to be avoided include those that have been aged, pickled, fermented, or smoked. Patients taking MAOIs can eat potatoes (Option A), baked chicken (Option C), and cottage cheese (Option C) in reasonable amounts.
5. A hospitalized patient is in a manic phase of bipolar I disorder. When developing the nursing care plan for this patient, the nurse should anticipate that in social interactions, this individual’s behavior is very likely to be: (Select all that apply.)
A. Unpredictable.
B. Isolative
C. Demanding
D. Competitive.
E. Indecisive.
5. Correct Answers: Options A, C, & D. Providing nursing care to patients with an elevated mood or mania can be especially challenging for the nurse. The patient will usually be excited, physically hyperactive, labile, and unpredictable. Patients in manic states tend to show behaviors that are controlling, competitive, irritable, aggressive, and domineering in social situation. They are often socially intrusive and inappropriate. If their demands are not met, they can easily become aggressive in ways that are dangerous to self or others. The nurse should always consider the person in a manic state to be at risk for injury to self or especially to others. These individuals will resist being alone and act as if they feel competed to interact with others at all times (Option B). Patients in a manic state have unrealistically high self-esteem, often believing they are the smartest people in the world. Thus, they will not hesitate to make decisions (Option E), but these decisions are made impulsively, without regard for consequences.
6. A patient states, “I just want to sleep all the time. I am overweight again. I will go to work and do my grocery shopping, but that’s all. My life’s a mess.” The nurse should conclude that which nursing diagnosis is most relevant?
A. Ineffective coping
B. Risk for violence: self-directed
C. Activity intolerance
D. Anxiety
6. Correct Answer: Option A. The patient is describing symptoms that are consistent with those of a mood disorder. The individual’s life is not well managed, nor does he or she experience pleasure. There is nothing in the statement to indicate an immediate risk for violence (Option B). the patient is dispirited and dissatisfied, but does not indicate that this is overwhelming enough to cause self-destructive ideas or urges. The statement does not suggest inability to tolerate physical activity (Option C), but rather fatigue and disinterest. Activity intolerance is much more intense and specific than fatigue. Nothing in the statement implies that acute anxiety is present (Option D). Anxiety is a common human experience, but in order for it to be a nursing diagnosis, there should be clear evidence that the anxiety level is elevated to an uncomfortable level.
7. A patient in an inpatient unit is awake at 1 a.m. and tells the nurse, “I can’t sleep because of the light in the hall and the noise from the kitchen. I need to have another sleeping pill.” The most appropriate nursing intervention is to:
A. Administer a prn sedative.
B. Move the patient to a quieter room.
C. Close the door to the patient’s room.
D. Allow the patient to watch TV for 1 hour.
7. Correct Answer: Option C. The patient has indicated that environmental noise and activity are preventing sleep. The nurse should first attempt to minimize environmental stimuli. Simply closing the door is a noninvasive, non-stimulating strategy that may work, assuming that it does not pose a safety hazard for the patient. Before administering a prn sedative (Option A), the nurse should attempt other nonpharmacological options. It is not necessary to move the patient (Option B) when closing the door can produce a noninvasive strategy. However, the door should not be closed if this would pose a risk for safety. Turing on the TV (Option D) will increase the amount of noise in the room and could further stimulate the patient.
1. Which of the following would the nurse interpret as negative symptoms? Select all that apply.
A. Poverty of speech
B. Hallucinations
C. Delusions
D. Affective blunting
E. Avolition
F. Tangentiality
1. Options A, D, & E. Negative symptoms of schizophrenia include alogia (which includes poverty of speech or its ontents), affective blunting, and avolition. Positive symptoms include hallucination, delusions, and tangentiality.
2. A patient diagnosed with schizophrenia says, “Everyone here is part of Satan’s police and wants to torture me”, and refuses to be weighed by a staff member. What is the most therapeutic response by the nurse?
A. “That is a strange idea. We don’t work for Satan.”
B. “That must be a frightening thought to have. We are nurses who work at this hospital.”
C. “Being suspicious isn’t easy, is it? I promise you won’t be tortured here.”
D. “You have nothing to be afraid of here. We’re going to make you well.”
2. Option B. The patient is experiencing a delusion and believes that the nursing staff members are “Satan’s police”. Understandably, the patient will be distrusting, suspicious, and frightened of all actions of the staff. The nurse should show awareness of the feelings of this patient (“That must be a frightening thought to have.”) and present reality about the role of the nursing staff (“We are nurses who work at this hospital).) Option A demeans the patient and fails to allow the patient to know the staff’s role. Option C attempts to respond to the patient’s feelings and present reality, but it does not tell the patient about the role of the staff. Option D attempts to be reassuring, but it fails to give reality-based information and promises too much (“We’re going to make you well”).
3. A patient diagnosed with schizophrenia, paranoid type, is admitted to an acute care psychiatric hospital unit. Which nursing diagnosis should be given the highest priority in the initial nursing care plan?
A. Interrupted thought processes
B. Social isolation
C. Impaired verbal communication
D. Risk for violence directed at self or at others
3. Option D. Safety is always the highest priority when caring for any patient. This is especially true when the patient has paranoid schizophrenia. These individuals are extremely suspicious and distrusting of the environment and feel that others have harmful intent toward them. They maintain an alert and watchful hypervigilance and are at high risk for aggression and/or violence. Interrupted though processes (Option A), social isolation (Option B), and impaired verbal communication (Option C) are appropriate for the patient’s care plan but are not given highest priority, as they are not as important as safety.
4. A patient is to begin taking olanzapine (Zyprexa). The nurse makes it a priority to assess which of the following before administering the first dose?
A. Usual sleep pattern
B. Food and fluid preferences
C. Body weight
D. History of indigestion
4. Option C. Increase in body weight and body mass index (BMI) can occur very quickly when patients take olanzapine (Zyprexa). Baseline data about these should be obtained before the patient begins to take this drug. Determining the patient’s sleep pattern (Option A) is not an urgent consideration, although the nurse should recognize that daytime somnolence might be an early side effect of this drug. Food and fluid preferences (Option B) are important considerations when the nurse teaches the patient about usual side effects, but this can be done later. While some patients do have digestive disturbances (Option D) while taking olanzapine (Zyprexa), this is not nearly as common as the side effect of rapid weight gain.
5. A patient diagnosed with schizophrenia tells the nurse that another patient is “creating negative thoughts in me against my will”. The nurse documents that the client is exhibiting which of the following features of schizophrenia?
A. Thought broadcasting
B. Thought blocking
C. Thought insertion
D. Thought control
5. Option C. Thought insertion is a thought disorder of schizophrenia that is defined as the patient believing that others are putting thoughts in his or her mind against the patient’s will. Thought broadcasting (Option A) is the belief by a patient that he or she can broadcast his or her thoughts to others. Thought blocking (Option B) occurs when a patient’s thoughts stop in midstream. Thought control (Option D) is the belief that others can control one’s thoughts against his or her will.
6. A patient taking antipsychotic medications for treatment of schizophrenia reports feeling nervous. The nurse notices that the patient is pacing the hallway, tries to sit down, but is unable to stay sitting—even when in conversation with others. The nurse suspects the patient is experiencing
A. Akathisia
B. Akinesia
C. Dystonia
D. Tardive dyskinesia
6. Option A. Akathisia in an extrapyramidal side effect of antipsychotic medications that may manifest as subjective and objective restlessness and increased motor movement. Akinesia (Option B) is also an extrapyramidal symptom, but it is not shown in this patient’s behavior. Akinesia is decreased activity or motor movement. Dystonia (Option C) is also an extrapyramidal side effect, but it is not shown in this patient’s behavior. Dystonia presents as sudden and often painful contractions of muscles, especially of the head and neck. Tardive dyskinesia (Option D) presents as involuntary muscle movements, strange tics, and repetitive motor movements in persons who have taken antipsychotics for a long period of time. The situation gives no medication history of the patient.
7. A patient admitted to an inpatient unit has a diagnosis of schizophrenia, paranoid type. A nursing student approaches the charge nurse and asks about the best way to work with this patient. How should the nurse respond?
A. “When possible, remain at arm’s length from this patient.”
B. “This patient is anxious. Offer backrubs at bedtime.”
C. “Offer this patient a hand-shake before beginning conversation.”
D. “To get the patient’s attention, place your hand gently on the arm or hand.”
7. Option A. Patients with paranoid schizophrenia are very suspicious and potentially dangerous. It is best to avoid any physical contact, as well as any symbolic or actual invasions of personal space because the individual may feel threatened. Offering a back rub (Option B), shaking hands (Option C), and placing a hand on the patient (Option D) involve physical contact. It is unlikely that the patient could tolerate this without becoming uncomfortable or even aggressive.
1. Which nursing diagnosis supports the psychoanalytic theory of development of major depressive disorder?
1. Social isolation R / T self-directed anger.
2. Low self-esteem R / T learned helplessness.
3. Risk for suicide R / T neurochemical imbalances.
4. Imbalanced nutrition less than body requirements R / T weakness.
1. Social isolation R/T self-directed anger supports the psychoanalytic theory in the development of major depressive disorder (MDD). Freud defines melancholia as a profoundly painful dejection and cessation of interest in the outside world, which culminates in a delusional expectation of punishment. He observed that melancho- lia occurs after the loss of a love object. Freud postulated that when the loss has been incorporated into the self (ego), the hostile part of the ambivalence that has been felt for the lost object is turned inward toward the ego. Another way to state this concept is that the client turns anger toward self.
Which client statement is evidence of the etiology of major depressive disorder from a genetic perspective?
1. “My maternal grandmother was diagnosed with bipolar affective disorder.”
2. “My mood is a 7 out of 10, and I won’t harm myself or others.”
3. “I am so angry that my father left our family when I was 6.”
4. “I just can’t do anything right. I am worthless.”
1. A family history of mood disorder indicates a genetic predisposition to the develop- ment of major depressive disorder. Twin, family, and adoptive studies further support a genetic link as an etiological influence in the development of mood disorders.
During an intake assessment, which client statement is evidence of the etiology of major depressive disorder from an object-loss theory perspective?
1. “I am so angry all the time and seem to take it out on myself.”
2. “My grandmother and great-grandfather also had depression.”
3. “I just don’t think my life is ever going to get better. I can’t do anything right.”
4. “I don’t know about my biological family; I was in foster care as an infant.”
4. Object-loss theorists suggest that depres- sive illness occurs as a result of being abandoned by or otherwise separated from a significant other during the first
6 months of life. The client in the ques- tion experienced parental abandonment, and according to object loss theory, this loss has led to the diagnosis of MDD.
Which statement about the development of bipolar disorder is from a biochemical per- spective?
1. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%.
2. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium.
3. Magnetic resonance imaging studies have revealed enlarged third ventricles, subcor- tical white matter, and periventricular hyperintensity in individuals diagnosed with
bipolar disorder.
4. Twin studies have indicated a concordance rate among monozygotic twins of 60% to
80%.
2. Alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium, is an example of a biochemi- cal perspective in the development of bipolar disorder.
5. Which statement describes a major difference between a client diagnosed with major depressive disorder and a client diagnosed with dysthymic disorder?
1. A client diagnosed with dysthymic disorder is at higher risk for suicide.
2. A client diagnosed with dysthymic disorder may experience psychotic features.
3. A client diagnosed with dysthymic disorder experiences excessive guilt.
4. A client diagnosed with dysthymic disorder has symptoms for at least 2 years.
4. An individual suspected to have dysthymic disorder needs to experience symptoms for at least 2 years before a diagnosis can be made. The essential feature is a chron- ically depressed mood (or possibly an irritable mood in children and adoles- cents) for most of the day, more days than not, for at least 2 years (1 year for chil- dren and adolescents). Clients with a diagnosis of MDD show impaired social and occupational functioning that has existed for at least 2 weeks.
6. A client expresses frustration and hostility toward the nursing staff regarding the lack of care his or her recently deceased parent received. According to Kubler-Ross, which stage of grief is this client experiencing?
1. Anger.
2. Disequilibrium.
3. Developing awareness.
4. Bargaining.
Kubler-Ross’s five stages of grief consist of denial, anger, bargaining, depression, and acceptance.
1. The client in the question is exhibiting
anger surrounding the death of a parent. Kubler-Ross describes anger as the second stage in the normal grief response. This stage occurs when clients experience the reality of the situation. Feelings associated with this stage include sadness, guilt, shame, helplessness, and hopelessness.
7. A client plans and follows through with the wake and burial of a child lost in an auto- mobile accident. Using Engel’s model of normal grief response, in which stage would this client fall?
1. Resolution of the loss.
2. Recovery.
3. Restitution.
4. Developing awareness.
3. The client in the question is exhibiting signs associated with Engel’s stage of restitution. Restitution is the third stage of Engel’s model of the normal grief response. In this stage, the various rituals associated with loss within a culture are performed. Examples include funerals, wakes, special attire, a gathering of friends and family, and religious practices customary to the spiritual beliefs of the bereaved.
8. Which charting entry most accurately documents a client’s mood?
1. “The client expresses an elevation in mood.”
2. “The client appears euthymic and is interacting with others.”
3. “The client isolates self and is tearful most of the day.”
4. “The client rates mood at a 2 out of 10.”
4. The use of a mood scale objectifies the subjective symptom of mood as a pain scale objectifies the subjective symptom of pain. The use of scales is the most accu- rate way to assess subjective data.
9. Which client is at highest risk for the diagnosis of major depressive disorder?
1. A 24-year-old married woman.
2. A 64-year-old single woman.
3. A 30-year-old single man.
4. A 70-year-old married man.
1. Research indicates that depressive symptoms are highest among young, married women of low socioeconomic backgrounds. Compared with the other clients presented, this client is at highest risk for the diagnosis of major depressive disorder (MDD).
10. A client is admitted to an in-patient psychiatric unit with a diagnosis of major depres- sive disorder. Which of the following data would the nurse expect to assess? Select all that apply.
1. Loss of interest in almost all activities and anhedonia.
2. A change of more than 5% of body weight in 1 month.
3. Fluctuation between increased energy and loss of energy.
4. Psychomotor retardation or agitation.
5. Insomnia or hypersomnia.
1.Loss of interest in almost all activities and anhedonia, the inability to experience or even imagine any pleasant emotion, are symptoms of major depressive disorder (MDD).
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2. Significant weight loss or gain of more than 5% of body weight in 1 month is one of the many diagnostic criteria for MDD.
4. Psychomotor retardation or agitation, occurring nearly every day, is a diagnostic criterion for MDD. These symptoms should be observable by others and not merely subjective feelings of restlessness or lethargy.
5. Sleep alterations, such as insomnia or hypersomnia, that occur nearly every day are diagnostic criteria for MDD.
11. A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms?
1. “Rates mood as 4/10.”
2. “Expresses thoughts of poor self-esteem during group.”
3. “Became irritable and agitated on waking.”
4. “Rates anxiety as 2/10 after receiving lorazepam (Ativan).”
3. When the client becomes irritable and agitated on awakening, the client is exhibiting behavioral symptoms of depression. Other behavioral symptoms include, but are not limited to, tearfulness, restlessness, slumped posture, and withdrawal.
12. Which symptom is an example of physiological alterations exhibited by clients diag- nosed with moderate depression?
1. Decreased libido.
2. Difficulty concentrating.
3. Slumped posture.
4. Helplessness.
1. Decreased libido is a physiological alteration exhibited by clients diagnosed with
moderate depression.
13. Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression?
1. Apathy.
2. Somatic delusion.
3. Difficulty falling asleep.
4. Social isolation.
1. Apathy is defined as indifference, insensi-
bility, and lack of emotion. Apathy is an affective alteration exhibited by clients diagnosed with severe depression.
14. Major depressive disorder would be most difficult to detect in which of the following clients?
1. A 5-year-old girl.
2. A 13-year-old boy.
3. A 25-year-old woman.
4. A 75-year-old man.
2. Assessment of depressive disorders in 13- year-old children would include feelings of sadness, loneliness, anxiety, and hopeless- ness. These symptoms may be perceived as normal emotional stresses of growing up. Many teens whose symptoms are attributed to the “normal adjustments” of adolescence, are not accurately diagnosed and do not get the help they need.
15. Which is the key to understanding if a child or adolescent is experiencing an underly- ing depressive disorder?
1. Irritability with authority.
2. Being uninterested in school.
3. A change in behaviors over a 2-week period.
4. Feeling insecure at a social gathering.
3. Change in behavior is an indicator that differentiates mood disorders from the typical stormy behaviors of adolescence. Depression can be a common manifestation of the stress and independence conflicts associated with the normal maturation process. Assessment of normal baseline behaviors would help the nurse recognize changes in behaviors that may indicate underlying depressive disorders.
16. The nurse in the emergency department is assessing a client suspected of being suici- dal. Number the following assessment questions, beginning with the most critical and ending with the least critical.
___ “Are you currently thinking about suicide?”
___ “Do you have a gun in your possession?”
___ “Do you have a plan to commit suicide?”
___ “Do you live alone? Do you have local friends or family?”
16. The correct order of these assessment ques- tions is 1, 3, 2, 4.
(1) Assessment of suicidal ideations must occur before any other assessment data are gathered. If the client
is not considering suicide, continuing with the suicide assessment is unnecessary.
(2) Assessment of a suicide plan is next. A client’s risk for suicide increases if the client has developed a specific plan.
(3) Assessment of the access to the means to commit suicide is next. The ability for the client to access the means to carry out the suicide plan is an important assessment for the nurse to inter- vene appropriately. If a client has a loaded gun available to him or her at home, the nurse would be responsible to assess this information and initiate actions to decrease the client’s access.
(4) Assessment of the client’s potential for rescue is next. If a client has an involved support system, even if a suicide attempt occurs, there is a potential for rescue. Without an involved support system, the client is at higher risk
17. Which nursing charting entry is documentation of a behavioral symptom of mania?
1. “Thoughts fragmented, flight of ideas noted.”
2. “Mood euphoric and expansive. Rates mood a 10/10.”
3. “Pacing halls throughout the day. Exhibits poor impulse control.”
4. “Easily distracted, unable to focus on goals.”
3. When the nurse documents, “Pacing halls throughout the day. Exhibits poor impulse control,” the nurse is charting a behavioral symptom of mania. Psychomotor activities and uninhibited social and sexual behaviors are classified as behavioral symptoms.
18. A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first?
1. A client on one-to-one status because of active suicidal ideations.
2. A client pacing the hall and experiencing irritability and flight of ideas.
3. A client diagnosed with hypomania monopolizing time in the milieu.
4. A client with a history of mania who is to be discharged in the morning.
2.Most assaultive behavior that occurs on an in-patient unit is preceded by a period of increasing hyperactivity. A client’s behavior of pacing the halls and experiencing irritability should be considered emergent and warrant immediate attention. Because of these symptoms, this client would need to be assessed first.
19. A nurse is planning to teach about appropriate coping skills. The nurse would expect which client to be at the highest level of readiness to participate in this instruction?
1. A newly admitted client with an anxiety level of 8/10 and racing thoughts.
2. A client admitted 6 days ago for a manic episode refusing to take medications.
3. A newly admitted client experiencing suicidal ideations with a plan to overdose.
4. A client admitted 6 days ago for suicidal ideations following a depressive episode.
4. A client admitted 6 days ago for suicidal ideations has begun to stabilize because of the treatment received during this timeframe. Compared with the other clients described, this client would have the highest level of readiness to participate in instruction.
20. A newly admitted client has been diagnosed with major depressive disorder. Which nursing diagnosis takes priority?
1. Social isolation R / T poor mood AEB refusing visits from family.
2. Self-care deficit R / T hopelessness AEB not taking a bath for 2 weeks.
3. Anxiety R / T hospitalization AEB anxiety rating of an 8/10.
4. Risk for self-directed violence R / T depressed mood.
4. Risk for self-directed violence is the priori- ty diagnosis for a newly admitted client diagnosed with MDD. Risk for self-directed violence is defined as behaviors in which the individual demonstrates that he or she can be physically harmful to self. This is a life-threatening problem that requires immediate prioritization by the nurse.
21. A client’s outcome states, “The client will make a plan to take control of one life situ- ation by discharge.” Which nursing diagnosis documents the client’s problem that this outcome addresses?
1. Impaired social interaction.
2. Powerlessness.
3. Knowledge deficit.
4. Dysfunctional grieving.
2. Powerlessness is defined as the perception that one’s own action would not significantly affect an outcome—a perceived lack of control over a current situation or immediate happening. Because the client outcome presented in the question addresses the lack of control over life situations, the nursing diagnosis of powerlessness documents this client’s problem.
22. Which nursing diagnosis takes priority for a client immediately after electroconvulsive therapy (ECT)?
1. Risk for injury R / T altered mental status.
2. Impaired social interaction R / T confusion.
3. Activity intolerance R / T weakness.
4. Chronic confusion R / T side effect of ECT.
1. Immediately after electroconvulsive therapy (ECT), risk for injury R / T altered mental status is the priority nursing diagnosis. The most common side effect of ECT is memory loss and confusion, and these place the client at risk for injury.
23. A client diagnosed with major depressive disorder has been newly admitted to an in- patient psychiatric unit. The client has a history of two suicide attempts by hanging. Which nursing diagnosis takes priority?
1. Risk for violence directed at others R / T anger turned outward.
2. Social isolation R / T depressed mood.
3. Risk for suicide R / T history of attempts.
4. Hopelessness R / T multiple suicide attempts.
3. Risk for suicide R / T history of attempts is a priority nursing diagnosis for a client who is diagnosed with major depression and has a history of two suicide attempts by hanging. A history of a suicide attempt increases a client’s risk for future attempts. Because various means can be used to hang oneself, the client is at risk for accessing these means, even on an in- patient unit. These factors would cause the nurse to prioritize this safety concern.
24. A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority?
1. Altered thought processes R / T biochemical alterations.
2. Social isolation R / T grandiosity.
3. Disturbed sleep patterns R / T agitation.
4. Risk for violence: self-directed R / T depressive symptoms.
3. Disturbed sleep patterns is defined as a time-limited disruption of sleep amount and quality. Because the client is sleeping only 2 hours a night, the client is meeting the defining characteristics of the nursing diagnosis of disturbed sleep patterns. This sleep problem is usually due to excessive hyperactivity and agitation.
25. A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is a priority at this time?
1. Risk for violence: other-directed R / T poor impulse control.
2. Altered thought process R / T hallucinations.
3. Social isolation R / T manic excitement.
4. Low self-esteem R / T guilt about promiscuity.
1. Risk for violence: other-directed is defined as behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to others. Because of poor impulse control, irritability, and hyperactive psychomotor behaviors experienced during a manic episode, this client is at risk for violence directed toward others. Keeping all clients in the milieu safe is always a nursing priority.
26. A client admitted with major depressive disorder has a nursing diagnosis of ineffective sleep pattern R / T aches and pains. Which is an appropriate short-term outcome for this client?
1. The client will express feeling rested on awakening.
2. The client will rate pain level at or below a 4/10.
3. The client will sleep 6 to 8 hours at night by day5
4. The client will maintain a steady sleep pattern while hospitalized.
3. The appropriate short-term outcome for the nursing diagnosis of ineffective sleep pattern R/T aches and pains is to expect the client to sleep 6 to 8 hours a night by day 5. This outcome is client-specific, realistic, and measurable, and includes a timeframe.
27. Which client would the charge nurse assign to an agency nurse working on the in- patient psychiatric unit for the first time?
1. A client experiencing passive suicidal ideations with a past history of an attempt.
2. A client rating mood as 3/10 and attending but not participating in group therapy.
3. A client lying in bed all day long in a fetal position and refusing all meals.
4. A client admitted for the first time with a diagnosis of major depression.
2. Although this client rates mood low, there is no indication of suicidal ideations, and the client is attending groups in the milieu. Because this client is observable in the milieu by all staff members, assignment to an agency nurse would be appropriate
28. A client has a nursing diagnosis of risk for suicide R / T a past suicide attempt. Which outcome, based on this diagnosis, would the nurse prioritize?
1. The client will remain free from injury throughout hospitalization.
2. The client will set one realistic goal related to relationships by day 3.
3. The client will verbalize one positive attribute about self by day 4.
4. The client will be easily redirected when discussion about suicide occurs by day 5.
1. Remaining free from injury throughout hospitalization is a priority outcome for the nursing diagnosis of risk for suicide R / T a past suicide attempt. Because this outcome addresses client safety, it is prioritized.
29. A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R / T biochemical alterations. Based on this diagnosis, which outcome would be appropriate?
1. The client will not experience injury throughout the shift.
2. The client will interact appropriately with others by day 3.
3. The client will be compliant with prescribed medications.
4. The client will distinguish reality from delusions by day 6.
4. Distinguishing reality from delusions by day 6 is an appropriate outcome for the nursing diagnosis of disturbed thought processes R/T biochemical alterations. Altered thought processes have improved when the client can distinguish reality from delusions.
30. The nurse is reviewing expected outcomes for a client diagnosed with bipolar I disorder. Number the outcomes presented in the order in which the nurse would address them.
___ The client exhibits no evidence of physical injury.
___ The client eats 70% of all finger foods offered.
___ The client is able to access available out-patient resources.
___ The client accepts responsibility for own behaviors.
30. The order in which the outcomes should be addressed is 1, 2, 4, 3. (1) The nurse would address the outcome that states, “The client exhibits no evidence of physical injury,” first because this outcome deals with client physi- cal safety. (2) Next, the nurse would address the outcome that states, “The client eats 70% of all finger foods offered,” because this outcome deals with the client’s physical needs. (3) The nurse would address next the outcome that states, “The client accepts responsibility for own behaviors,” because this outcome is realistic only later in treat- ment. (4) Finally, the nurse would address the outcome that states, “The client is able to access available out-patient resources,” because this outcome would be appropriate only during the discharge process.
31. A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R / T egocentrism. Which short-term outcome is an appropriate expecta- tion for this client problem?
1. The client will have an appropriate one-on-one interaction with a peer by day 4.
2. The client will exchange personal information with peers at lunchtime.
3. The client will verbalize the desire to interact with peers by day 2.
4. The client will initiate an appropriate social relationship with a peer.
1. A client’s having an appropriate one-on-
one interaction with a peer is a successful outcome for the nursing diagnosis of impaired social interaction. The test taker should note that this outcome is specific, client-centered, positive, realistic, and measurable, and includes a timeframe.
32. A suicidal Jewish-American client is admitted to an in-patient psychiatric unit 2 days after the death of a parent. Which intervention must the nurse include in the care of this client?
1. Allow the client time to mourn the loss during this time of shiva.
2. To distract the client from the loss, encourage participation in unit groups.
3. Teach the client alternative coping skills to deal with grief.
4. Discuss positive aspects the client has in his or her life to build on strengths.
1. In the Jewish faith, the 7-day period beginning with the burial is called shiva. During this time, mourners do not work, and no activity is permitted that diverts attention from thinking about the deceased. Because this client’s parent died 2 days ago, the client needs time to participate in this religious ritual.
33. A client denying suicidal ideations comes into the emergency department complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first?
1. Request a psychiatric consultation.
2. Complete a thorough physical assessment including lab tests.
3. Remove all hazardous materials from the environment.
4. Place the client on a one-to-one observation.
2. Numerous physical conditions can contribute to symptoms of insomnia, including irritability, anorexia, and depressed mood. It is important for the nurse to rule out these physical problems before assuming that the symptoms are psychological in nature. The nurse can do this by completing a thorough physical assess- ment including lab tests.
34. A client diagnosed with major depressive disorder has a nursing diagnosis of low self- esteem R / T negative view of self. Which cognitive intervention by the nurse would be appropriate to deal with this client’s problem?
1. Promote attendance in group therapy to assist client to socialize.
2. Teach assertiveness skills by role-playing situations.
3. Encourage the client to journal to uncover underlying feelings.
4. Focus on strengths and accomplishments to minimize failures.
4. Focusing on strengths and accomplishments to minimize failures is a cognitive intervention by the nurse. Cognitive interventions focus on altering distortions of thoughts and negative thinking.
35. A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship?
1. Sit with the client and offer self frequently.
2. Notify the client of group therapy schedule.
3. Introduce the client to others on the unit.
4. Help the client to identify stressors of life that precipitate life crises.
1. Offering self is one technique to generate the establishment of trust with a newly admitted client diagnosed with major depressive disorder (MDD). Trust is the basis for the establishment of any nurse- client relationship.
36. A client diagnosed with major depressive disorder is being considered for electrocon- vulsive therapy (ECT). Which client teaching should the nurse prioritize?
1. Empathize with the client about fears regarding ECT.
2. Monitor for any cardiac alterations to avoid possible negative outcomes.
3. Discuss with the client and family expected short-term memory loss.
4. Inform the client that injury related to induced seizure commonly occurs.
3. An expected and acceptable side effect of ECT is short-term memory loss. It is important for the nurse to teach the client and family members this information to avoid unnecessary anxiety about this symptom.
37. Which intervention takes priority when working with newly admitted clients experi- encing suicidal ideations?
1. Monitor the client at close, but irregular, intervals.
2. Encourage the client to participate in group therapy.
3. Enlist friends and family to assist the client to remain safe after discharge.
4. Remind the client that it takes 4 to 6 weeks for antidepressants to be fully effective.
1. Clients who experience suicidal ideations must be monitored closely to prevent suicide attempts. By monitoring at irregular intervals, the nurse would prevent the client from recognizing patterns of obser- vation. If a client does recognize patterns of observations, the client can use the time in which he or she is not observed to plan and implement a suicide attempt.
38. A client notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority?
1. Place the client on a one-to-one observation.
2. Determine if the client has a specific plan to commit suicide.
3. Assess for past history of suicide attempts.
4. Notify all staff members and place the client on suicide precautions.
2. Assessment is the first step in the nursing process. Assessing a client’s plan for suicide would give the nurse the information needed to intervene appropriately and therefore should be prioritized.
39. A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse’s priority intervention?
1. Place the client on a one-to-one to avoid injury.
2. Ask the physician for a psychiatric consultation.
3. Assess vital signs, and complete physical assessment.
4. Reinforce relaxation techniques to decrease anxiety.
3. The nurse first should assess vital signs and complete a physical assessment to rule out a physical cause for the symptoms presented. Many physical problems manifest in symptoms that seem to be caused by psychological problems.
40. A client experiencing mania states, “Everything I do is great.” Using a cognitive approach, which nursing response would be most appropriate?
1. “Is there a time in your life when things didn’t go as planned?”
2. “Everything you do is great.”
3. “What are some other things you do well?”
4. “Let’s talk about the feelings you have about your childhood.”
1. By asking, “Is there a time in your life when things didn’t go as planned?” the nurse is using a cognitive approach to challenge the thought processes of the client.
41. A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client’s a nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client?
1. Chicken fingers and French fries.
2. Grilled chicken and a baked potato.
3. Spaghetti and meatballs.
4. Chili and crackers.
1. Chicken fingers and French fries are finger foods, which the client would be able to eat during increased psychomotor activity, such as pacing. Because these foods are high in caloric value, they also meet the client’s increased nutritional needs.
42. A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation?
1. Join the milieu to assess the appropriateness of the laughter.
2. Redirect clients in the milieu to structured social activities, such as cards.
3. Privately discuss with the client the inappropriateness of provocative dress during hospitalization.
4. Administer PRN antianxiety medication to calm the client.
3. Because dressing provocatively can precipitate sexual overtures that can be dangerous to the client, it is the priority of the nurse to discuss with the client the inappropriateness of this clothing choice.
43. A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority?
1. Calmly redirect and remove the client from the milieu.
2. Administer prescribed PRN intramuscular injection for agitation.
3. Notify the client to lower voice.
4. Obtain an order for seclusion to help decrease external stimuli.
1. When a client experiencing mania is yelling at other peers, it is the nurse’s priority to address this situation immediately. Behaviors of this type can escalate into violence toward clients and staff members. By using a calm manner, the nurse avoids generating any further hostile behaviors, and by removing the client from the milieu, the nurse protects other clients on the unit.
44. A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R / T extreme hyperactivity. Which nursing intervention is appropriate?
1. Place the client in a room with another client experiencing similar symptoms.
2. Use PRN antipsychotic medications as ordered by the physician.
3. Discuss consequences of the client’s behaviors with the client daily.
4. Reinforce previously learned coping skills to decrease agitation.
2. A newly admitted client experiencing an extremely hyperactive episode as the result of bipolar I disorder would benefit from an antipsychotic medication to sedate the client quickly. Lithium carbonate (lithium) should be given concurrently for maintenance therapy and to prevent or diminish the intensity of subsequent manic episodes.
45. A client diagnosed with bipolar I disorder experienced an acute manic episode and was admitted to the in-patient psychiatric unit. The client is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply.
1. Financial and legal assistance.
2. Crisis hotline.
3. Individual psychotherapy.
4. Support groups.
5. Family education groups.
1. During a manic episode, clients are likely to experience impulse control problems, which may lead to excessive spending. Having access to financial and legal assistance may help the client assess the situation and initiate plans to deal with financial problems.
2. During a manic episode, a client may not eat or sleep and may abuse alcohol or other drugs. The client’s hyperactivity may lead to ambivalence regarding his or her desire to live. Having access to a crisis hotline may help the client to de-escalate and make the difference between life and death decisions.
3. During a manic episode, a client most likely would have had difficulties in various aspects of interpersonal relationships, such as family, friends, and coworkers. Individuals experiencing mania may be difficult candidates for psychotherapy because of their inability to focus. When the acute phase of the illness has passed, the client may decide to access an available resource to deal with interpersonal problems. Psychotherapy, in conjunction with medication maintenance treatment, and counseling may be useful in helping these individuals.
4. During a manic episode, a client would not be a willing candidate for any type of group therapy. However, when the acute phase of the illness has passed, this individual may want to access support groups to benefit therapeutically from peer support.
5. During a manic episode, a client may have jeopardized marriage or family functioning. Having access to a resource that would help this client restore adaptive family functioning may improve not only relationships, but also noncompliance issues and dysfunctional behavioral pat- terns, and ultimately may reduce relapse rates. Family therapy is most effective with the combination of psychotherapeutic and pharmacotherapeutic treatment.
46. A nursing student is studying major depressive disorder. Which student statement indi- cates that learning has occurred?
1. “1% of the population is affected by depression yearly.”
2. “2% to 5% of women experience depression during their lifetimes.”
3. “1% to 3% of men become clinically depressed.”
4. “Major depression is a leading cause of disability in the United States.”
4. Major depression is one of the leading causes of disability in the United States. This is not to be confused with an occa- sional bout with the “blues,” a feeling of sadness or downheartedness. Such feelings are common among healthy individuals and are considered a normal response to everyday disappointments in life.
47. A client has a nursing diagnosis of dysfunctional grieving R / T loss of a job AEB inabil- ity to seek employment because of sad mood. Which would support a resolution of this client’s problem?
1. The client reports an anxiety level of 2 out of 10 and denies suicidal ideations.
2. The client exhibits trusting behaviors toward the treatment team.
3. The client is noted to be in the denial stage of the grief process.
4. The client recognizes and accepts the role he or she played in the loss of the job.
4. Accepting responsibility for the role played in a loss indicates that the client has moved forward in the grieving process and resolved the problem of dysfunctional grieving.
48. A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders?
1. “When clients experience loss, they learn that it is inevitable and become hopeless
and helpless.”
2. “There are alterations in the neurochemicals, such as serotonin, which cause the
client’s symptoms.”
3. “Evidence continues to support multiple causations related to an individual’s suscep-
tibility to mood symptoms.”
4. “There is a genetic component affecting the development of mood disorders.”
3. When the student states that there is support for multiple causations related to an individual’s susceptibility to mood symptoms, the student understands the content presented about the etiology of mood disorders.
49. A nursing instructor is presenting statistics regarding suicide. Which student statement indicates that learning has occurred?
1. “Approximately 10,000 individuals in the United States commit suicide each year.”
2. “Almost 95% of all individuals who commit or attempt suicide have a diagnosed
mental disorder.”
3. “Suicide is the eighth leading cause of death among young Americans 15 to 24 years
old.”
4. “Depressive disorders account for 70% of all individuals who commit or attempt
suicide.”
2. Almost 95% of all individuals who commit or attempt suicide have a diagnosed mental disorder. Most suicides are associated with mood disorders.
50. A client diagnosed with major depressive disorder has an outcome that states, “The client will verbalize a measure of hope about future by day 3.” Which client statement indicates this outcome was successful?
1. “I don’t want to die because it would hurt my family.”
2. “I need to go to group and get out of this room.”
3. “I think I am going to talk to my boss about conflicts at work.”
4. “I thank you for your compassionate care.”
3. When the client begins to plan how to deal with conflicts at work, the client is focusing on a hopeful future. This indicates that the outcome of verbalizing a measure of hope about the future by day 3 has been successful.
51. A nursing instructor is teaching about the psychosocial theory related to the develop- ment of bipolar disorder. Which student statement would indicate that learning has occurred?
1. “The credibility of psychosocial theories in the etiology of bipolar disorder has
strengthened in recent years.”
2. “Bipolar disorder is viewed as a purely genetic disorder.”
3. “Following steroid, antidepressant, or amphetamine use, individuals can experience
manic episodes.”
4. “The etiology of bipolar disorder is unclear, but it is possible that biological and psy-
chosocial factors are influential.”
4. The etiology of bipolar disorder is unclear; however, research evidence shows that biological and psychosocial factors are influential in the develop- ment of the disorder.
52. A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client’s use of grandiosity. Which is the rationale for this nurse’s action?
1. Understanding the reason behind a behavior would assist the nurse to accept and
relate to the client, not the behavior.
2. Change cannot occur until the client can accept responsibility for behaviors.
3. As self-esteem is increased, the client will meet needs without the use of manipula-
tion.
4. Positive reinforcement would enhance self-esteem and promote desirable behaviors.
1. Grandiosity, which is defined as an exaggerated sense of self-importance, power, or status, is used by clients diagnosed with bipolar affective disorder to help reduce feelings of insecurity by increasing feelings of power and control. When the nurse understands the origin of this behavior, the nurse can better work with, and relate to, the client.
53. A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disor- der. Which student statement indicates that learning has occurred?
1. “Clients diagnosed with bipolar II disorder experience a full syndrome of mania and
have a history of symptoms of depression.”
2. “Clients diagnosed with bipolar II disorder experience numerous episodes of hypo-
mania and dysthymia for at least 2 years.”
3. “Clients diagnosed with bipolar II disorder have mood disturbances that are directly
associated with the physiological effects of a substance.”
4. “Clients diagnosed with bipolar II disorder experience recurrent bouts of depression
with episodic occurrences of hypomania.”
4. Recurrent bouts of depression and episodic occurrences of hypomania are diagnostic criteria for bipolar II disorder. Experiencing a full manic episode would indicate a diagnosis of bipolar I disorder and rule out a diagnosis of bipolar II disorder.
54. Which of the following medications may be administered before electroconvulsive therapy? Select all that apply.
1. Glycopyrrolate (Robinul).
2. Thiopental sodium (Pentothal).
3. Succinylcholine chloride (Anectine).
4. Lorazepam (Ativan).
5. Divalproex sodium (Depakote).
1. Glycopyrrolate (Robinul) is given to decrease secretions and counteract the effects of vagal stimulation induced by electroconvulsive therapy (ECT).
2. Thiopental sodium (Pentothal) is a short- acting anesthetic medication administered to produce loss of consciousness during ECT.
3. Succinylcholine chloride (Anectine) is a muscle relaxant administered to prevent severe muscle contractions during the seizure, reducing the risk for fractured or dislocated bones.
55. A client diagnosed with major depressive disorder is prescribed phenelzine (Nardil). Which teaching should the nurse prioritize?
1. Remind the client that the medication takes 4 to 6 weeks to take full effect.
2. Instruct the client and family about the many food-drug and drug-drug interactions.
3. Teach the client about the possible sexual side effects and insomnia that can occur.
4. Educate the client about the need to take the medication even after symptoms have
improved.
2. Because there are numerous drug-food and drug-drug interactions that may precipitate a hypertensive crisis during treatment with MAOIs, it is critical that the nurse prioritize this teaching.
56. A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms?
1. Amitriptyline (Elavil) and divalproex sodium (Depakote).
2. Verapamil (Calan) and topiramate (Topamax).
3. Lithium carbonate (Eskalith) and clonazepam (Klonopin).
4. Risperidone (Risperdal) and lamotrigine (Lamictal).
4. Risperidone (Risperdal), an antipsychotic, directly addresses the auditory hallucinations experienced by the client. Lamotrigine (Lamictal), a mood stabilizer, would address the classic symptoms of bipolar I disorder.
57. A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client’s lithium serum level would be which of the following?
1. 0.6 mEq/L.
2. 1.5 mEq/L.
3. 2.6 mEq/L.
4. 3.5 mEq/L.
3. A client with a lithium serum level of
2.6 mEq/L may experience an excessive output of dilute urine, tremors, muscular irritability, psychomotor retardation, and mental confusion. The client’s symptoms described in the question support a lithium serum level of 2.6 mEq/L.
58. A client diagnosed with major depressive disorder is newly prescribed sertraline (Zoloft). Which of the following teaching points would the nurse review with the client? Select all that apply.
1. Monitor the client for suicidal ideations related to depressed mood.
2. Discuss the need to take medications, even when symptoms improve.
3. Instruct the client about the risks of abruptly stopping the medication.
4. Alert the client to the risks of dry mouth, sedation, nausea, and sexual side effects.
5. Remind the client that the medication’s full effect does not occur for 4 to 6 weeks.
2. Discussing the need for medication compliance, even when symptoms improve, is a teaching point that the nurse would need to review with a client who is newly prescribed sertraline.
3. Instructing the client about the risk for discontinuation syndrome is a teaching point that the nurse would need to review with a client who is newly prescribed sertraline.
4. Alerting the client to the risks of dry mouth, sedation, nausea, and sexual side effects is a teaching point that the nurse would need to review with a client who is newly prescribed sertraline.
5. Reminding the client that sertraline’s full effect does not occur for 4 to 6 weeks is a teaching point that the nurse would need to review with a client who is newly pre- scribed sertraline.
59. Which symptoms would the nurse expect to assess in a client suspected to have sero- tonin syndrome?
1. Alterations in mental status, restlessness, tachycardia, labile blood pressure, and diaphoresis.
2. Hypomania, akathisia, cardiac arrhythmias, and panic attacks.
3. Dizziness, lethargy, headache, and nausea.
4. Orthostatic hypotension, urinary retention, constipation, and blurred vision.
1. Alterations in mental status, restlessness,
tachycardia, labile blood pressure, and diaphoresis all are symptoms of serotonin syndrome. If this syndrome were suspected, the offending agent would be discontinued immediately.
60. Which medication would be classified as a tricyclic antidepressant?
1. Bupropion (Wellbutrin).
2. Mirtazapine (Remeron).
3. Citalopram (Celexa).
4. Nortriptyline (Pamelor).
4. Nortriptyline (Pamelor) is classified as a tricyclic antidepressant. Other tricyclic antidepressants include amitriptyline (Elavil), doxepin (Sinequan), and imipramine (Tofranil).
1. Although symptoms of schizophrenia occur at various times in the life span, what client would be at highest risk for the diagnosis?
1. A 10-year-old girl.
2. A 20-year-old man.
3. A 50-year-old woman.
4. A 65-year-old man.
2. Symptoms of schizophrenia generally appear in late adolescence or early adulthood. Some studies have indicated that symptoms occur earlier in men than in women.
2. A nursing instructor is teaching about the etiology of schizophrenia. What statement by the nursing student indicates an understanding of the content presented?
1. “Schizophrenia is a disorder of the brain that can be cured with the correct
treatment.”
2. “A person inherits schizophrenia from a parent.”
3. “Problems in the structure of the brain cause schizophrenia.”
4. “There are lots of potential causes for this disease, and this is continues to be a controversial topic.”
4. The etiology of schizophrenia remains unclear. No single theory or hypothesis has been postulated that substantiates a clear-cut explanation for this disease. The more research that is conducted, the more evidence is compiled to support the concept of multiple causes in the development of schizophrenia. The most current theory seems to be that schizophrenia is a biologically based disease with a genetic component. The onset of the disease also is influenced by factors in the internal and external environment.
3. What is required for effective treatment of schizophrenia?
1. Concentration on pharmacotherapy alone to alter imbalances in neurotransmitters.
2. Multidisciplinary, comprehensive efforts, which include pharmacotherapy and psy-
chosocial care.
3. Emphasis on social and living skills training to help the client fit into society.
4. Group and family therapy to increase socialization skills.
2. Effective treatment of schizophrenia requires a comprehensive, multidisciplinary effort, including pharmacotherapy and various forms of psychosocial care. Psychosocial care includes social and living skills training, rehabilitation, and family therapy.
4. When one fraternal twin has been diagnosed with schizophrenia, the other twin has approximately a _____ % chance of developing the disease.
15%
5. When one identical twin has been diagnosed with schizophrenia, the other twin has approximately a _____ % chance of developing the disease.
50%
6. From a biochemical influence perspective, which accurately describes the etiology of schizophrenia?
1. Children born of nonschizophrenic parents and raised by parents diagnosed with
schizophrenia have a higher incidence of diagnosis.
2. An excess of dopamine-dependent neuronal activity in the brain.
3. A higher incidence of schizophrenia occurs after prenatal exposure to influenza.
4. Poor parent-child interaction and dysfunctional family systems.
2. The dopamine hypothesis suggests that schizophrenia may be caused by an excess of dopamine-dependent neuronal activity in the brain. This excess activity may be related to increased production, or release, of the substance at nerve terminals; increased receptor sensitivity; too many dopamine receptors; or a combination of these mechanisms. This etiological theory is from a biochemical influence perspective.
7. From a sociocultural perspective, which accurately describes the etiology of schizo- phrenia?
1. Relatives of individuals diagnosed with schizophrenia have a much higher probabil- ity of developing the disease.
2. Structural brain abnormalities, such as enlarged ventricles, cause schizophrenia.
3. Disordering of pyramidal cells in the hippocampus contributes to the cause of schiz-
ophrenia.
4. Greater numbers of individuals from lower socioeconomic backgrounds are diag-
nosed with schizophrenia
4. Statistically, there are greater numbers of individuals from lower socioeconomic backgrounds diagnosed with schizophrenia. This is evidence from a sociocultural perspective for the etiology of schizophrenia. It is unclear whether this increased diagnosis may occur because of a lower socioeconomic situation or because the disease itself can contribute to a lower socioeconomic status.
8. A nurse is working with a client diagnosed with schizoid personality disorder. What symptom of this diagnosis should the nurse expect to assess, and at what risk is this client for acquiring schizophrenia?
1. Delusions and hallucinations—high risk.
2. Limited range of emotional experience and expression—high risk.
3. Indifferent to social relationships—low risk.
4. Loner who appears cold and aloof—low risk.
2. Individuals diagnosed with schizoid personality disorder are indifferent to social relationships and have a very limited range of emotional experience and expression. They do not enjoy close relationships and prefer to be loners. They appear cold and aloof. Not all individuals who demonstrate the characteristics of schizoid personality disorder progress to schizophrenia, but most individuals diagnosed with schizophrenia show evidence of the characteristics of schizoid personality disorder pre-morbidly, putting them at high risk for schizophrenia.
9. A nurse is assessing a client in the mental health clinic. The client has a long history of being a loner and has few social relationships. This client’s father has been diagnosed with schizophrenia. The nurse would suspect that this client is in what phase in the development of schizophrenia?
1. Phase I—schizoid personality.
2. Phase II—prodromal phase.
3. Phase III—schizophrenia.
4. Phase IV—residual phase.
1. Individuals diagnosed with schizoid personality disorder are typically loners who appear cold and aloof and are indifferent to social relationships. Not all individuals who demonstrate the characteristics of schizoid personality disorder progress to schizophrenia, but because of a family history of schizophrenia, this client’s risk for acquiring the disease increases from 1% in the general population to 10%.
10. A nurse is assessing a client in the mental health clinic 6 months after the client’s dis- charge from in-patient psychiatric treatment for schizophrenia. The client has no active symptoms, but has a flat affect and has recently been placed on disability. What should the nurse document?
1. “The client is experiencing symptoms of the schizoid personality phase of the devel- opment of schizophrenia.”
2. “The client is experiencing symptoms of the prodromal phase of the development of schizophrenia.”
3. “The client is experiencing symptoms of schizophrenia.”
4. “The client is experiencing symptoms of the residual phase of the development of schizophrenia.”
4. Symptoms during the residual phase are similar to those of the prodromal phase, with flat affect and impairment in role function being prominent. This client has recently experienced an active phase of schizophrenia and has been placed on disability, indicating problems with role functioning. The nurse would recognize the symptoms presented as an indication that the client is in the residual phase of schizophrenia.
11. A client diagnosed with schizophrenia is brought to the emergency department by a family member. The client is experiencing social withdrawal, flat affect, and impair- ment in role functioning. To distinguish whether this client is in the prodromal or residual phase of schizophrenia, what question would the nurse ask?
1. “Has this client recently experienced an exacerbation of the signs and symptoms of schizophrenia?”
2. “How long have these symptoms been occurring?”
3. “Has the client had a change in mood?”
4. “Has the client been diagnosed with any developmental disorders?”
1. It is important for the nurse to know if this client has recently experienced an active phase of schizophrenia to distinguish the symptoms presented as indications of the prodromal or residual phase of schizophrenia. Schizophrenia is characterized by periods of remission and exacerbation. A residual phase usually follows an active phase of the illness. Symptoms during the residual phase are similar to those of the prodromal phase, with flat affect and impairment in role function being prominent.
12. The nurse is assessing a client diagnosed with disorganized schizophrenia. Which symptoms should the nurse expect the client to exhibit?
1. Markedly regressive, primitive behavior, and extremely poor contact with reality.
Affect is flat or grossly inappropriate. Personal appearance is neglected, and social
impairment is extreme.
2. Marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movements and activity. Waxy
flexibility is exhibited.
3. The client is exhibiting delusions of persecution or grandeur. Auditory hallucinations related to a persecutory theme are present. The client is tense, suspicious, and
guarded, and may be argumentative, hostile, and aggressive.
4. The client has a history of active psychotic symptoms, but prominent psychotic
symptoms are currently not exhibited.
1. When a client exhibits markedly regressive and primitive behavior, and the client’s contact with reality is extremely poor, he or she is most likely to be diagnosed with disorganized schizophrenia. In this subcategory, a client’s affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme.
13. On an in-patient unit, the nurse is caring for a client who is assuming bizarre positions for long periods of time. To which diagnostic category of schizophrenia would this client most likely be assigned?
1. Disorganized schizophrenia.
2. Catatonic schizophrenia.
3. Paranoid schizophrenia.
4. Undifferentiated schizophrenia.
2. A client diagnosed with catatonic schizophrenia exhibits marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movements and activity. Waxy flexibility is exhibited. Waxy flexibility is a type of posturing or voluntary assumption of bizarre positions in which the individual may remain for long periods. Efforts to move the individual may be met with rigid bodily resistance. The client described in the question is exhibiting signs and symptoms of catatonic schizophrenia.
14. A nurse is admitting a client to the in-patient unit who is exhibiting bizarre delusions, auditory hallucinations, and incoherent speech. The client is experiencing suicidal ideations and rates mood at 2/10. Based on this clinical picture, the client is manifesting symptoms in what diagnostic category?
1. Paranoid schizophrenia.
2. Brief psychotic disorder.
3. Schizoaffective disorder.
4. Schizophreniform disorder.
3. Schizoaffective disorder is manifested by schizophrenic behaviors with a strong element of symptoms associated with the mood disorders (mania or depression). The client may appear depressed with suicidal ideations. When the mood disorder has been assessed, the decisive factor in the diagnosis is the presence of characteristic schizophrenia symptoms, such as bizarre delusions, prominent hallucinations, or incoherent speech.
15. A new graduate nurse is assessing a 20-year-old client in the emergency department. The client is seeing and hearing things that others do not see or hear. The nurse tells the supervisor, “I believe the client has schizophrenia.” Which of the following super- visor responses is the most appropriate? Select all that apply.
1. “How long has the client experienced these symptoms?”
2. “Has the client taken any drug or medication that could cause these symptoms?”
3. “It is not within your scope of practice to assess for a medical diagnosis.”
4. “Does this client have any mood problems?”
5. “What kind of relationships has this client established?”
1. The duration of symptoms is an important
finding to assess to determine the diagnosis of schizophrenia. One of the DSM-IV- TR criteria is that symptoms need to be present for a significant amount of time during a 1-month period and last for
6 months.
2. A substance or general medical condition
exclusion is an important finding to assess to determine the diagnosis of schizophrenia. One of the DSM-IV-TR criteria is that the presenting symptoms are not due to the direct physiological effects of the use or abuse of a substance or medication.
4. The presence of mood disorders is an important finding to assess to determine the diagnosis of schizophrenia. Schizo- affective disorder and mood disorder with psychotic features must be ruled out for the client to meet the criteria for this diagnosis. No major depressive, manic, or mixed episodes should have occurred con- currently with the active-phase symptoms. If mood episodes have occurred during the active-phase symptoms, their total duration should have been brief, relative to the duration of the active and residual periods.
5. The ability to form relationships is an important finding to assess to determine the diagnosis of schizophrenia. One of the DSM-IV-TR criteria for this diagnosis is a disturbance in one or more major areas of functioning, such as work, interpersonal relationships, or self-care. When the onset is in adolescence, there should be a failure to achieve expected levels of interpersonal or academic functioning.
16. A 21-year-old client, being treated for asthma with steroid medication, has been expe- riencing delusions of persecution and disorganized thinking for the past 6 months. Which factor may rule out a diagnosis of schizophrenia?
1. The client has experienced signs and symptoms for only 6 months.
2. The client must hear voices to be diagnosed with schizophrenia.
3. The client’s age is not typical for this diagnosis.
4. The client is receiving medication that could lead to thought disturbances.
4. Steroid medications could precipitate the thought disorders experienced by the client and potentially rule out the diagnosis of schizophrenia. According to the DSM-IV- TR criteria for this diagnosis, the thought disturbance cannot be due to the direct physiological effects of a substance.
17. A client is brought to the emergency department after being found wandering the streets and talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client?
1. If the client exhibits a developmental disorder, such as autism.
2. If the client has a medical condition that could contribute to the symptoms.
3. If the client experiences manic or depressive signs and symptoms.
4. If the client’s signs and symptoms last for 6 months.
4. The client’s signs and symptoms lasting for 6 months is further evidence for the diagnosis of schizophrenia. Two or more characteristic symptoms must be present for a significant amount of time during a 1-month period and must last for 6 months to meet the criteria for the diagnosis of schizophrenia.
18. A client on an in-patient psychiatric unit refuses to take medications because, “The pill has a special code written on it that will make it poisonous.” What kind of delusion is this client experiencing?
1. An erotomanic delusion.
2. A grandiose delusion.
3. A persecutory delusion.
4. A somatic delusion.
3. A persecutory delusion is a type of delusion in which the individual believes he or she is being malevolently treated in some way. Frequent themes include being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. The situation described in the question reflects this type of delusion.
19. The nurse is performing an admission assessment on a client diagnosed with paranoid schizophrenia. To receive the most accurate assessment information, which should the nurse consider?
1. This client will be able to make a significant contribution to history data collection.
2. Much data will need to be gained by reviewing old records and talking with family
members and significant others.
3. Assessment of this client will be simple because of the commonly occurring nature
of the disease process of schizophrenia.
4. The nurse will refer to the client’s global assessment of functioning score to deter-
mine client problems and nursing interventions.
2. Background assessment information must be gathered from numerous sources, including family members and old records. A client in an acute episode would be unable to provide accurate and insightful assessment information because of deficits in communication and thought.
20. The nurse is interviewing a client who states, “The dentist put a filling in my tooth; I now receive transmissions that control what I think and do.” The nurse accurately documents this symptom with which charting entry?
1. “Client is experiencing a delusion of persecution.”
2. “Client is experiencing a delusion of grandeur.”
3. “Client is experiencing a somatic delusion.”
4. “Client is experiencing a delusion of influence.”
4. A delusion of influence or control occurs when a client believes certain objects or persons have control over his or her behavior. The statement of the client is reflective of a delusion of influence.
21. The children’s saying, “Step on a crack and you break your mother’s back,” is an example of which type of thinking?
1. Concrete thinking.
2. Thinking using neologisms.
3. Magical thinking.
4. Thinking using clang associations.
3. Magical thinking occurs when the individual believes that his or her thoughts or behaviors have control over specific situations or people. It is commonly seen during cognitive development in childhood. The statement presented is an example of magical thinking.
22. The nurse is assessing a client diagnosed with schizophrenia. The client states, “We wanted to take the bus, but the airport took all the traffic.” Which charting entry accu- rately documents this symptom?
1. “The client is experiencing associative looseness.”
2. “The client is attempting to communicate by the use of word salad.”
3. “The client is experiencing delusional thinking.”
4. “The client is experiencing an illusion involving planes.”
1. Associative looseness is thinking characterized by speech in which ideas shift from one unrelated subject to another. The client is unaware that the topics are unconnected. The client statement is an example of associative looseness.
23. The nurse reports that a client diagnosed with a thought disorder is experiencing religiosity. Which client statement would confirm this finding?
1. “I see Jesus in my bathroom.”
2. “I read the Bible every hour so that I will know what to do next.”
3. “I have no heart. I’m dead and in heaven today.”
4. “I can’t read my Bible because the CIA has poisoned the pages.”
2. The statement, “I read the Bible every hour so that I will know what to do next,” is evidence of the symptom of religiosity. Religiosity is an excessive demonstration of or obsession with religious ideas and behavior. The client may use religious ideas in an attempt to provide rational meaning and structure to behavior.
24. The nurse states, “It’s time for lunch.” A client diagnosed with schizophrenia responds, “It’s time for lunch, lunch, lunch.” Which type of communication process is the client using, and what is the underlying reason for its use?
1. Echopraxia, which is an attempt to identify with the person speaking.
2. Echolalia, which is an attempt to acquire a sense of self and identity.
3. Unconscious identification to reinforce weak ego boundaries.
4. Depersonalization to stabilize self-identity.
2. When clients diagnosed with schizophrenia repeat words that they hear, they are exhibiting echolalia. This is an indication of alterations in the client’s sense of self. Weak ego boundaries cause these clients to lack feelings of uniqueness. Echolalia is an attempt to identify with the person speaking.
25. Clients diagnosed with schizophrenia may have difficulty knowing where their ego boundaries end and others’ begin. Which client behavior reflects this deficit?
1. The client eats only prepackaged food.
2. The client believes that family members are adding poison to food.
3. The client looks for actual animals when others state, “It’s raining cats and dogs.”
4. The client imitates other people’s physical movements.
4. When clients imitate other people’s physical movements, they are experiencing echopraxia. The behavior of echopraxia is an indication of alterations in the client’s sense of self. These clients have difficulty knowing where their ego boundaries end and others’ begin. Weak ego boundaries cause these clients to lack feelings of uniqueness. Echopraxia is an attempt to identify with others.
26. The nurse documents that a client diagnosed with schizophrenia is expressing a flat affect. What is an example of this symptom?
1. The client laughs when told of the death of the client’s mother.
2. The client sits alone and does not interact with others.
3. The client exhibits no emotional expression.
4. The client experiences no emotional feelings.
3. Flat affect is described as affect devoid of emotional tone. Having no emotional expression is an indication of flat affect.
27. Which client is most likely to benefit from group therapy?
1. A client diagnosed with schizophrenia being followed up in an out-patient clinic.
2. A client diagnosed with schizophrenia newly admitted to an in-patient unit for stabilization.
3. A client experiencing an exacerbation of the signs and symptoms of schizophrenia.
4. A client diagnosed with schizophrenia who is not compliant with antipsychotic
medications.
1. Group therapy for clients diagnosed with thought disorders has been shown to be effective, particularly in an out-patient setting and when combined with medication management.
28. In the United States, which diagnosis has the lowest percentage of occurrence?
1. Major depressive disorder.
2. Generalized anxiety disorder.
3. Obsessive-compulsive disorder.
4. Schizophrenia.
4. In the United States, the prevalence of schizophrenia is 1%. Approximately 1.7 million American adults are diagnosed with the brain disorder of schizophrenia.
29. A client who is hearing and seeing things others do not is brought to the emergency department. Lab values indicate a sodium level of 160 mEq/L. Which nursing diagno- sis would take priority?
1. Altered thought processes R/T low blood sodium levels.
2. Altered communication processes R/T altered thought processes.
3. Risk for impaired tissue integrity R/T dry oral mucous membranes.
4. Imbalanced fluid volume R/T increased serum sodium levels.
4. All physiological problems must be corrected before evaluating thought disorders. In this situation, the psychotic symptoms may be related to the critically high sodium level. If the cause is physiological in nature, the nurse’s priority is to assist in correcting the physiological problem. If the client’s fluid volume imbalance is corrected, the psychotic symptoms, which are due to the medical condition of hypernatremia, would be eliminated, resulting in an improvement in thought process symptoms. This would improve the client’s ability to communicate effectively and decrease the risk of dry mucous membranes.
30. A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing diagnosis addresses concerns regarding this client’s problem?
1. Disturbed thought processes.
2. Disturbed sensory perception.
3. Risk for suicide.
4. Impaired verbal communication.
3. Risk for suicide is defined as a risk for self-inflicted, life-threatening injury. The negative symptom of anhedonia is defined as the inability to experience pleasure. This is a particularly distressing symptom that generates hopelessness and compels some clients to attempt suicide.
31. A client diagnosed with a thought disorder is experiencing clang associations. Which nursing diagnosis reflects this client’s problem?
1. Impaired verbal communication.
2. Risk for violence.
3. Ineffective health maintenance.
4. Disturbed sensory perception.
1. Impaired verbal communication is defined as the decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols. Clang associations are choices of words that are governed by sound. Words often take the form of rhyming. An example of a clang association is “It is cold. I am bold. The gold has been sold.” This type of language is an impairment to verbal communication.
32. A client states, “I can’t go into my bathroom because there is a demon in the tub.” Which nursing diagnosis reflects this client’s problem?
1. Self-care deficit.
2. Ineffective health maintenance.
3. Disturbed sensory perception.
4. Disturbed thought processes.
3. Disturbed sensory perception is defined as a change in the amount or patterning of incoming stimuli (either internally or externally initiated), accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. The client’s statement in the question indicates that the client is experiencing a visual hallucination, which is an example of a dis- turbed sensory perception.
33. A client diagnosed with a thought disorder has body odor and halitosis and is disheveled. Which nursing diagnosis reflects this client’s problem?
1. Social isolation.
2. Impaired home maintenance.
3. Interrupted family processes.
4. Self-care deficit.
4. Self-care deficit is defined as the impaired ability to perform or complete activities of daily living. The client’s symptoms of body odor, halitosis, and a disheveled appearance are directly related to a self- care deficit problem.
34. A client’s family is having a difficult time accepting the client’s diagnosis of schizophrenia, and this has led to family conflict. Which nursing diagnosis reflects this problem?
1. Impaired home maintenance.
2. Interrupted family processes.
3. Social isolation.
4. Disturbed thought processes.
2. The nursing diagnosis of interrupted family processes is defined as a change in family relationships or functioning or both. This nursing diagnosis is reflected in the family’s conflict related to an inability to accept the family member’s diagnosis of schizophrenia.
35. A client diagnosed with paranoid schizophrenia tells the nurse about three previous suicide attempts. Which nursing diagnosis would take priority and reflect this client’s problem?
1. Disturbed thought processes.
2. Risk for suicide.
3. Violence: directed toward others.
4. Risk for altered sensory perception.
2. Risk for suicide is defined as the risk for self-inflicted, life-threatening injury. A past history of suicide attempts greatly increases the risk for suicide and makes this an appropriate diagnosis for this client. Because client safety is always the main consideration, this diagnosis should be prioritized.
36. A client has the nursing diagnosis of impaired home maintenance R/T regression. Which behavior confirms this diagnosis?
1. The client fails to take antipsychotic medications.
2. The client states, “I haven’t bathed in a week.”
3. The client lives in an unsafe and unclean environment.
4. The client states, “You can’t draw my blood without crayons.”
3. Impaired home maintenance can be related to regression, withdrawal, lack of knowledge or resources, or impaired physical or cognitive functioning in clients experiencing thought disorders. This is evidenced by an unsafe, unclean, disorderly home environment.
37. Which outcome should the nurse expect from a client with a nursing diagnosis of social isolation?
1. The client will recognize distortions of reality by day 4
2. The client will use appropriate verbal communication when interacting with others by day 3.
3. The client will actively participate in unit activities by discharge.
4. The client will rate anxiety as 5/10 by discharge.
3. Actively participating in unit activities by discharge is an outcome for the nursing diagnosis of social isolation. Participation in unit activities indicates interaction with others on the unit, which leads to decreased social isolation.
38. Which outcome should the nurse expect from a client diagnosed with schizophrenia who is hearing and seeing things others do not hear and see?
1. The client will recognize distortions of reality by discharge.
2.The client will demonstrate the ability to trust by day2
3. The client will recognize delusional thinking by day 3.
4. The client will experience no auditory hallucinations by discharge.
1. When a client is hearing and seeing things others do not, the client is experiencing a hallucination, which is an altered sensory perception. A hallucination is defined as a false sensory perception not associated with real external stimuli. Hallucinations may involve any of the five senses. Because schizophrenia is a chronic disease, some individuals, even when compliant with antipsychotic medications, continue to experience hallucinations. Recognizing distortions of reality by discharge is an appropriate outcome for the nursing diagnosis of altered sensory perception.
39. A client admitted to an in-patient setting has not been compliant with antipsychotic medications prescribed for schizophrenia. Which outcome related to this client’s problem should the nurse expect the client to achieve?
1. The client will maintain anxiety at a reasonable level by day 2.
2. The client will take antipsychotic medications by discharge.
3. The client will communicate to staff any paranoid thoughts by day 3.
4. The client will take responsibility for self-care by day4
2. Taking antipsychotic medications by discharge is an appropriate outcome for this client’s problem of noncompliance. The outcome is realistic, client-centered, and measurable.
40. A client taking olanzapine (Zyprexa) has a nursing diagnosis of altered sensory perception R/T command hallucinations. Which outcome would be appropriate for this client’s problem?
1. The client will verbalize feelings related to depression and suicidal ideations.
2. The client will limit caloric intake because of the side effect of weight gain.
3. The client will notify staff members of bothersome hallucinations.
4. The client will tell staff members if experiencing thoughts of self-harm.
3. When the client has the insight to recognize hallucinations and report them to staff members, the client is in better touch with reality and moving toward remission. This is an outcome that relates to the client’s problem of altered sensory perception. Reporting to staff members also can assist in preventing the client from following through with the commands given by auditory hallucinations.
41. A homeless client being seen in the mental health clinic complains of an infestation of insects on the skin. Which intervention would the nurse implement first?
1. Check the client for body lice.
2. Present reality regarding somatic delusions.
3. Explain the origin of persecutory delusions.
4. Refer for in-patient hospitalization because of substance-induced psychosis.
1. Before assuming that the client is experiencing a somatic delusion, the nurse first must rule out a physical cause for the client’s symptoms, such as body lice. A somatic delusion occurs when an individual has an unsubstantiated belief that he or she is experiencing a physical defect, disorder, or disease.
42. A client states to the nurse, “I see headless people walking down the hall at night.” Which nursing response is appropriate?
1. “What makes you think there are headless people here?”
2. “Now let’s think about this. A headless person would not be able to walk down the hall.”
3. “It must be frightening. I realize this is real to you, but there are no headless people
here.”
4. “I don’t see those people you are talking about.”
3. Empathizing with the client about the altered perception encourages trust and promotes further client communication about hallucinations. The nurse must follow this by presenting the reality of the situation. Clients must be assisted to accept that the perception is unreal to maintain reality orientation.
43. A client with a nursing diagnosis of disturbed thought processes has an expected out- come of recognizing delusional thinking. Which intervention would the nurse first implement to address this problem?
1. Reinforce and focus on reality.
2. Convey understanding that the client is experiencing delusional thinking.
3. Indicate that the nurse does not share the belief.
4. Present logical information to refute the delusional thinking.
2. When the nurse conveys understanding that the client is experiencing delusional thinking, the nurse is showing empathy for the client’s situation and building trust. This should be the first step to address the problem of disturbed thought processes. All further interventions would be based on the relationship’s being establiished by generating trust.
44. A client is in the active phase of paranoid schizophrenia. Which nursing intervention would aid in facilitating other interventions?
1. Assign consistent staff members.
2. Convey acceptance of the delusional belief.
3. Help the client understand the connection between anxiety and hallucinations.
4. Encourage participation in group activities.
1. Individuals with paranoia have extreme suspiciousness of others and their actions. It is difficult to establish trust with clients experiencing paranoia. All interventions would be suspect. Only by assigning consistent staff members would there be hope to establish a trusting nurse-client relationship and increase the effectiveness of further nursing interventions.
45. A client newly admitted to an in-patient psychiatric unit is scanning the environment continuously. Which nursing intervention is most appropriate to address this client’s behavior?
1. Offer self to build a therapeutic relationship with the client.
2. Assist the client to formulate a plan of action for discharge.
3. Involve the family in discussions about dealing with the client’s behaviors.
4. Reinforce the need for medication compliance on discharge.
1. The client described in the question is exhibiting signs of paranoia. Clients with this symptom have trouble trusting others. The nurse should use the therapeutic technique of offering self to assist in building a trusting therapeutic relationship with this client.
46. Which interaction is most reflective of an appropriate psychotherapeutic approach when interacting with a client diagnosed with schizophrenia?
1. The nurse should exhibit exaggerated warmth to counteract client loneliness.
2. The nurse should profess friendship to decrease social isolation.
3. The nurse should attempt closeness with the client to decrease suspiciousness.
4. The nurse should be honest and respect the client’s privacy to begin the establishment of a relationship.
4. Successful intervention may best be achieved with honesty, simple directness, and a manner that respects the client’s privacy and human dignity.
47. The nurse is interacting with a client diagnosed with schizophrenia. Number the nurse’s interventions in the correct sequence.
__ Present and refocus on reality.
__ Educate the client about the disease process.
__ Establish a trusting nurse-client relationship.
__ Empathize with the client about feelings generated by disease symptoms.
__ Encourage compliance with antipsychotic medications.
The correct sequence of nursing interventions is 3, 5, 1, 2, 4.
(1) The establishment of a trusting nurse-client relationship should be the first nursing intervention because
all further interventions will be affected by the trust the client has for the nurse.
(2) Empathizing with the client helps the nurse to connect with the client and enhances trust further.
(3) Presenting reality in a matter-of-fact way helps the client to distinguish what is real from what is not.
(4) Encouraging compliance with antipsychotic medications helps to decrease symptoms of the disorder and increases the client’s cooperation with psychosocial therapies.
(5) Educating the client about the disease process comes later in the therapeutic plan of care. A trusting nurse- client relationship has to be established and the client needs to be stabilized before initiating any effective teaching.
48. The nurse is educating the family members of a client diagnosed with schizophrenia about the effects of psychotherapy. Which statement should be included in the teaching plan?
1. “Psychotherapy is a short-term intervention that is usually successful.”
2. “Much patience is required during psychotherapy because clients often relapse.”
3. “Major changes in client symptoms can be attributed to immediate psychotherapy.”
4. “Independent functioning can be gained by immediate psychotherapy.”
2. The psychotherapist requires much patience when treating clients diagnosed with schizophrenia. Depending on the severity of the illness, psychotherapeutic treatment may continue for many years before clients regain some extent of independent functioning.
49. A client diagnosed with schizoid personality disorder asks the nurse in the mental health clinic, “Does this mean I will get schizophrenia?” What nursing response would be most appropriate?
1. “Does that possibility upset you?”
2. “Not all clients diagnosed with schizoid personality disorders progress to schizophrenia.”
3. “Few clients with a diagnosis of schizophrenia show evidence of early personality changes.”
4. “What do you know about schizophrenia?”
2. Not all individuals who demonstrate the characteristics of schizoid personality disorder progress to schizophrenia. However, most individuals diagnosed with schizophrenia show evidence of having schizoid personality characteristics in the premorbid condition.
50. Which intervention used for clients diagnosed with thought disorders is a behavioral therapy approach?
1. Offer opportunities for learning about psycotropic medications.
2. Attach consequences to adaptive and maladaptive behaviors.
3. Establish trust within a relationship.
4. Encourage discussions of feelings related to delusions.
2. When the nurse attaches consequences to adaptive or maladaptive behaviors, the nurse is using a behavioral therapy approach. Behavior therapy can be a powerful treatment tool for helping clients change undesirable behaviors.
51. Which intervention used for clients diagnosed with thought disorders is a milieu therapy approach?
1. Assist family members to deal with major upheavals in their lives caused by interactions with the client.
2. One-on-one interactions to discuss feelings.
3. Role-play to enhance motor and interpersonal skills.
4. Emphasize the rules and expectations of social interactions mediated by peer pressure.
4. When the nurse emphasizes the rules and expectations of social interactions mediated by peer pressure, the nurse is using a milieu therapy approach. Milieu therapy emphasizes group and social interaction. Rules and expectations are mediated by peer pressure for normalization of adaptation.
52. Which of the following clients has the best chance of a positive prognosis after being diagnosed with schizophrenia? Select all that apply.
1. A client diagnosed at age 35.
2. A male client experiencing a gradual onset of signs and symptoms.
3. A female client whose signs and symptoms began after a rape.
4. A client who has a family history of schizophrenia.
5. A client who has a family history of a mood disorder diagnosis.
1. Symptoms of schizophrenia generally appear in late adolescence or early adult- hood. Onset at a later age is associated with a more positive prognosis.
3. Abrupt onset of symptoms precipitated by a stressful event, such as rape, is associated with a more positive prognosis. Being female also is associated with a more positive prognosis.
5. A family history of mood disorder is associated with a more positive prognosis.
53. The nurse is teaching a client diagnosed with schizophreniform disorder about what may affect a good prognosis. Which of the following features should the nurse include? Select all that apply.
1. Confusion and perplexity at the height of the psychotic episode.
2. Good premorbid social and occupational functioning.
3. Absence of blunted or flat affect.
4. Predominance of negative symptoms.
5. Onset of prominent psychotic symptoms within 4 weeks of first noticeable change
in usual behavior or functioning.
1. Confusion and perplexity at the height of the psychotic episode is a feature of schizophreniform disorder that is thought to lead to a good prognosis. When the client is exhibiting perplexity, there is an element of insight that is absent in the more severe cases of cognitive impairment. This insight may lead to a future positive prognosis.
2. Good premorbid social and occupational functioning is a feature of schizophreniform disorder that is thought to lead to a good prognosis.
3. Absence of blunted or flat affect is a feature of schizophreniform disorder that is thought to lead to a good prognosis.
5. When the onset of prominent psychotic symptoms is within 4 weeks of the first noticeable change in usual behavior or functioning, a good prognosis is likely.
54. Which symptom experienced by a client diagnosed with schizophrenia would predict a less positive prognosis?
1. Hearing hostile voices.
2. Thinking the TV is controlling his or her behavior.
3. Continuously repeating what has been said.
4. Having little or no interest in work or social activities.
4. When a client has little or no interest in work or social activities, the client is exhibiting the negative symptom of apathy. Apathy is indifference to, or disinterest in, the environment. Flat affect is a manifestation of emotional apathy. Because this client is exhibiting a negative symptom, the client has the potential for a poorer prognosis.
55. The nurse is educating the family of a client diagnosed with schizophrenia about the importance of medication compliance. Which statement indicates that learning has occurred?
1. “After stabilization, the relapse rate is high, even if antipsychotic medications are
taken regularly.”
2. “My brother will have only about a 30% chance of relapse if he takes his medications consistently.”
3. “Because the disease is multifaceted, taking antipsychotic medications has little
effect on relapse rates.”
4. “Because schizophrenia is a chronic disease, taking antipsychotic medications has
have little effect on relapse rates.”
2. Research shows that with continuous antipsychotic drug treatment, the relapse rate of clients diagnosed with schizophrenia can be reduced to about 30%.
56. Which client has the best chance of a positive prognosis?
1. A client diagnosed with schizophrenia taking antipsychotic medications consistently.
2. A client diagnosed with schizophrenia participating in psychosocial therapies.
3. A client diagnosed with schizophrenia complying with antipsychotic medications
and participating in psychosocial therapies.
4. A client whose family provides psychosocial support.
3. Research shows that antipsychotic medications are more effective at all levels when combined with psychosocial therapies. Psychosocial therapies are more beneficial to the client when symptoms are controlled by antipsychotic medications. A combination of these therapies gives these clients the best chance for a positive prognosis.
57. The nurse documents that a client diagnosed with a thought disorder is experiencing anticholinergic side effects from long-term use of thioridazine (Mellaril). Which symptoms has the nurse noted?
1. Akinesia, dystonia, and pseudoparkinsonism.
2. Muscle rigidity, hyperpyrexia, and tachycardia.
3. Hyperglycemia and diabetes.
4. Dry mouth, constipation, and urinary retention.
4. Dry mouth, constipation, and urinary retention are anticholinergic side effects of antipsychotic medications such as thioridazine (Mellaril). Anticholinergic side effects are caused by agents that block parasympathetic nerve impulses. Thioridazine (Mellaril) has a high incidence of anticholinergic side effects.
58. The client has a long history of schizophrenia, which has been controlled by haloperidol (Haldol). During an admission assessment resulting from an exacerbation of the disease, the nurse notes continuous restlessness and fidgeting. Which medication would the nurse expect the physician to prescribe for this client?
1. Haloperidol (Haldol).
2. Fluphenazine decanoate (Prolixin Decanoate).
3. Clozapine (Clozaril).
4. Benztropine mesylate (Cogentin).
4. Benztropine mesylate (Cogentin) is an anticholinergic medication used for the treatment of extrapyramidal symptoms such as akathisia. The nurse would expect the physician to prescribe this drug for the client’s symptoms of restlessness and fidgeting.
59. The nurse is reviewing lab results for a client diagnosed with a thought disorder who is taking clozapine (Clozaril) 25 mg QD. The following values are documented: RBC 4.7 million/mcL, WBC 2000/mcL, and TSH 1.3 mc-IU. Which would the nurse expect the physician to order based on these values?
1. “Levothyroxine sodium (Synthroid) 150 mcg QD.”
2. “Ferrous sulfate (Feosol) 100 mg tid.”
3. “Discontinue clozapine (Clozaril).”
4. “Discontinue clozapine (Clozaril) and start levothyroxine sodium (Synthroid) 150 mcg QD.”
3. A normal adult value of white blood cell (WBC) count is 4500 to 10,000/mcL. This client’s WBC count is 2000/mcL, indicating agranulocytosis, which is a potentially fatal blood disorder. There is a significant risk for agranulocytosis with clozapine (Clozaril) therapy. The nurse would expect the physician to discontinue clozapine (Clozaril).
60. The nurse is discussing the side effects experienced by a female client taking antipsychotic medications. The client states, “I haven’t had a period in 4 months.” Which client teaching should the nurse include in the plan of care?
1. Antipsychotic medications can cause a decreased libido.
2. Antipsychotic medications can interfere with the effectiveness of birth control.
3. Antipsychotic medications can cause amenorrhea, but ovulation still occurs.
4. Antipsychotic medications can decrease red blood cells, leading to amenorrhea.
3. Antipsychotic medications can cause amenorrhea, but ovulation still occurs. If this client does not understand this, there is a potential for pregnancy. This is vital client teaching information that must be included in the plan of care.
32. A nursing student has a special feeling toward a client that is based on acceptance, warmth, and a nonjudgmental attitude. The student is experiencing which characteristic that enhances the achievement of the nurse-client relationship?
1. Rapport.
2. Trust.
3. Respect.
4. Professionalism.
1. Rapport is the primary task in relationship development. Rapport implies special feelings on the part of the nurse and the client. All other conditions necessary to establish the nurse-client relationship are based on the ability to connect and establish rapport.
33. The nurse’s ability to be open, honest, and real in interactions with clients is described as which characteristic that enhances the achievement of the nurse-client relationship?
1. Genuineness.
2. Empathy.
3. Objectivity.
4. Harmony.
1. Genuineness is the ability of the nurse to be open and real in interactions with clients. The nurse’s feelings, and the expression of these feelings, must be congruent to establish genuineness. Genuineness is a characteristic essential to the development of the nurse-client relationship.
34. Which is a nursing intervention that would promote the development of trust in the nurse-client relationship?
1. Simply and clearly providing reasons for policies and procedures.
2. Calling the client by name and title (“Mr. Hawkins”).
3. Striving to understand the motivations behind the client’s behavior.
4. Taking the client’s ideas into consideration when planning care.
1. By being given simple and clear reasons for policies and procedures, the client can count on consistency from the nurse in the implementation of these policies and procedures. This consistency promotes the development of trust in the nurse- client relationship.
35. In a psychiatric in-patient setting, the nurse observes an adolescent client’s peers call- ing the client names. In this context, which statement by the nurse exemplifies the concept of empathy?
1. “I can see that you are upset. Tell me how you feel.”
2. “Your peers are being insensitive. I would be upset also.”
3. “I used to be called names as a child. I know it can hurt feelings.”
4. “I get angry when people are treated cruelly.”
1. This empathetic statement appreciates the client’s feelings and objectively communicates concern for the client.
36. Which statement by the nurse expresses respect for the client?
1. “Because of your outbursts, and aggressive behavior, you will not be able to attend
the outing, Mr. Hawkins. I will spend time with you if you would like.”
2.”I assure you that what is discussed between us will stay within the health-care team.”
3. “I became angry when that other client pushed your buttons and made you mad.”
4. “Everyone loses it sometimes. You might just have a low boiling point.”
1. The nurse conveys a respectful attitude toward this client by focusing on the client’s dysfunctional behaviors and not labeling the client as dysfunctional. The nurse also addresses the client by name and title (“Mr. Hawkins”) and offers to spend time with him.
37. Which is the goal for the orientation phase of the nurse-client relationship?
1. Explore self-perceptions.
2. Establish trust.
3. Promote change.
4. Evaluate goal attainment.
2. The establishment of trust is the goal of the orientation phase. During this phase, a contract is established with the client.
38. Number the following nursing interventions as they would proceed through the phases of the nurse-client relationship.
___ Plan for continued care.
___ Promote client’s insight.
___ Examine personal biases.
___ Formulate nursing diagnoses.
The correct order is 4, 3, 1, 2.
(1) Examining personal biases occurs in the pre-orientation phase of the nurse-client relationship. (2) The formulation of nursing diagnostic statements occurs in the orienta- tion phase. (3) The promotion of client insight is a task of the working phase. (4) Planning for continued care occurs in the termination phase.
39. On an in-patient psychiatric unit, a client states, “I want to learn better ways to handle my anger.” This interaction is most likely to occur in which phase of the nurse-client relationship?
1. Pre-interaction phase.
2. Orientation (introductory) phase.
3. Working phase.
4. Termination phase.
2. The orientation (introductory) phase involves creating an environment that establishes trust and rapport. Another task of this phase includes establishing a con- tract for interventions that details the expectations and responsibilities of the nurse and the client. In this example, the client has built the needed trust and rap- port with the nurse. The client now feels comfortable and ready to acknowledge the problem and contract for intervention. Goal: Establish trust and formulate con- tract for intervention.
40. On an in-patient psychiatric unit, the nurse helps the client practice various techniques of assertive communication and gives positive feedback for attempting to improve passive-aggressive interactions. This interaction would occur in which phase of the nurse-client relationship?
1. Pre-interaction phase.
2. Orientation (introductory) phase.
3. Working phase.
4. Termination phase.
3. The working phase includes promoting the client’s insight and perception of reality, problem solving, overcoming resistant behaviors, and continuously evaluating progress toward goal attainment. In this example, the client works toward better communication and is guided and encouraged with positive feedback by the nurse. Goal: Promote client change.
41. On an in-patient psychiatric unit, the goals of therapy have been met, but the client cries and states, “I have to keep coming back to therapy to handle my anger better.” This interaction occurs in which phase of the nurse-client relationship?
1. Pre-interaction phase.
2. Orientation (introductory) phase.
3. Working phase.
4. Termination phase.
4. The termination phase occurs when progress has been made toward attainment of mutually set goals, a plan for continuing care is mutually established, and feelings about termination are recognized and explored. In this example, the nurse must establish the reality of separation and resist repeated delays by the client because of dependency needs. Goal: Evaluate goal attainment and ensure therapeutic closure.
42. On an in-patient psychiatric unit, the nurse explores feelings about working with a woman who continually has allowed her husband to abuse her and her children physically and verbally. This interaction would occur in which phase of the nurse-client relationship?
1. Pre-interaction phase.
2. Orientation (introductory) phase.
3. Working phase.
4. Termination phase.
1. The pre-interaction phase involves prepa- ration for the first encounter with the client, such as reading previous medical records and exploring feelings regarding working with that particular client. In this example, the nurse obtains information about the client for initial assessment. This also allows the nurse to become aware of any personal biases about the client. Goal: Explore self-perception.
43. The nurse reviews a client’s record in preparation for client care. This action is one of the tasks that occur in a stage of the nurse-client relationship. What is the purpose of this stage?
1. Getting to know each other and establishing trust.
2. Implementing nursing interventions to achieve outcomes.
3. Achievement of independence and maintenance of health without nursing care.
4. Understanding the signs and symptoms of the client’s diagnosis, and evaluating the
nurse’s attitudes.
4. Understanding the signs and symptoms of the client’s diagnosis and evaluating the nurse’s attitudes toward the client is the purpose of the pre-orientation stage of the nurse-client relationship.
44. The nurse explores any misconceptions or prejudices experienced before caring for a client. This action is one of the tasks that occur in a stage of the nurse-client relation- ship. What is the nurse’s major task in this stage?
1. Determining why the client sought help.
2. Exploring self.
3. Assisting the patient in behavioral change.
4. Establishing and preparing the client for the reality of separation.
2. The task of the nurse during the pre- interaction stage of the nurse-client relationship is to explore oneself.
45. In which stage of the nurse-client relationship is a contract for interaction formulated?
1. The stage in which the nurse explores misconceptions and prejudices related to
mental health issues.
2. The stage in which the nurse determines why the client sought help.
3. The stage in which the nurse explores stressors and promotes insight.
4. The stage in which the nurse evaluates the client’s progress and goal attainment.
2. During the orientation stage of the nurse- client relationship, the nurse determines why the client sought help. A contract for interaction is formulated during the orientation stage of the nurse-client relationship.
46. Which are elements of the nurse-client contract?
1. During the pre-interaction stage, the roles are established.
2. During the orientation stage, the purpose of the interaction is established.
3. During the working stage, the conditions for termination are established.
4. During the termination stage, the criteria for discharge are established.
2.During the orientation phase, the purpose of the interaction is established, and this is a component of the nurse-client contract.
47. A nursing student is experiencing fears related to the first clinical experience in a psychiatric setting. This is most likely to occur in which stage of the nurse-client relation- ship?
1. In the pre-interaction stage, because the student is likely to be suspicious of psychiatric clients.
2. In the orientation stage, because the psychiatric client may threaten the student’s
role identity.
3. In the working stage, because the student may feel emotionally vulnerable to past
experiences.
4.In the termination stage, because the student may be uncertain about his or her ability to make a difference.
1. Students may experience numerous fears related to working with psychiatric clients. Self-analysis in the pre-interaction stage of the nurse-client relationship may make the student aware of these fears. The student may be suspicious of psychiatric clients, feel inadequate about his or her ability to be therapeutic, or believe that there is a possibility of being harmed.
48. Which of the following are common feelings experienced by the novice nurse in an in- patient psychiatric setting? Select all that apply.
1. The informal nature of the setting allows increased creativity to develop nursing
interventions.
2. The newness of the experience can generate anxious behaviors by the nurse.
3. Preconceived thoughts and feelings about psychiatric clients can cause fear of client
violence.
4. Emotionally painful past experiences of the nurse can contribute to the nurse’s
inability to empathize with clients.
5. The nature of the locked psychiatric unit generates a feeling of security in the
novice nurse.
2. The newness of the experience may generate feelings of inadequate knowledge of the subject matter and fears of harming clients psychologically. This may lead to the nurse’s exhibiting anxious behaviors.
3. Preconceived thoughts and feelings about psychiatric clients generated by media portrayal can cause the nurse to assume that violence is a major issue, when in fact it is not.
4. Emotionally painful past experiences may cause the nurse to question his or her own mental health, project personal concerns on the clients, or sympathize versus empathize with the client’s situations.
5. A locked psychiatric unit is more apt to generate feelings of fear than of security.
49. Number in a logical series the skills that the nurse needs to interact therapeutically with clients.
___ Ability to communicate.
___ Ability to problem solve.
___ Ability to recognize signs and symptoms.
___ Ability to self-assess.
The logical sequence is 2, 4, 3, 1.
(1) Self-assessment occurs in the pre-interaction stage of the nurse-client relationship. Self-assessment must be completed for the nurse to understand potential preconceived thoughts and feelings about mentally ill clients, and how these feelings would affect the development of a relationship.
(2) The ability to communicate therapeutically is essential for any intervention that occurs in a psychiatric setting. Effective communication skills allow the nurse to assess a client’s thoughts, feelings, and symptoms and move toward effective interventions.
(3) After self- assessment and the development of effective communication skills, the nurse must have knowledge of the disease processes a client may be experiencing, and how the signs and symptoms exhibited relate to the disease.
(4) The nurse would be unable to intervene effectively and problem solve if there is a deficit in the nurse’s knowledge of the disorder.
50. The nursing student is experiencing a severe family crisis. In what way might this situation affect the student’s performance in a psychiatric rotation?
1. The student might over identify with clients and meet his or her own needs.
2. The student might fear clients and avoid them.
3. The student might feel inadequate and fear emotionally harming clients.
4. The student might doubt his or her value to assist clients because of lack of knowledge.
1. A nursing student who is experiencing a crisis situation may overidentify with clients and communicate or deal with personal problems, rather than focus on the clients’ problems and concerns. Instead of meeting the client’s needs, the student may makes his or her own needs the priority.
51. A belief is an idea that one holds to be true and comes in several forms. Which is an example of a statement that describes a concept in an oversimplified or undifferentiated manner?
1. Alcoholism is a disease.
2. After an alcoholic has been through detox and rehab, social drinking is permissible.
3. Belief in a higher power can help an alcoholic stop drinking.
4. All alcoholics are skid row bums.
4. A stereotypical belief, such as this, describes a concept in an oversimplified or undifferentiated manner.
52. Which of the following behaviors exemplifies the concept of countertransference? Select all that apply.
1. The nurse defends the client’s inappropriate behavior to the psychiatrist.
2. The nurse empathizes with the client’s loss.
3. The nurse subjectively appreciates the client’s feelings.
4. The nurse is uneasy when interacting with the client.
5. The nurse recognizes that the client is emotionally attached to the social worker.
1. Defending the client’s inappropriate behavior reflects an underlying subjective connection with the client, which is an example of countertransference.
4. The uneasiness that the nurse experiences reflects an underlying subjective connection with the client, which is an example of countertransference.
53. During a recent counseling session with a depressed client, the psychiatric nurse observes signs of transference. Which statement by the client would indicate that the nurse is correct?
1. “Thanks for taking my side against the staff.”
2. “You sure do remind me of my mom.”
3. “Working on problem solving together makes sense.”
4. “I won’t stop drinking just to please my whole family.”
2. This example of transference occurs when the client unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from his or her past. Transference also can take the form of overwhelming affection with unrealistic expectations from the nurse by the client. When the nurse does not meet the expectations, the client may become angry and hostile. Intervention: The nurse should work with the client in sorting out the past from the present, identifying the transference, and reassigning a more appropriate meaning to the nurse-client relationship.
54. The staff on a psychiatric unit observes a new nurse expressing anger and distrust while treating a client with a long history of alcoholism. The staff suspects that the nurse is using countertransference. Which statement by the nurse would indicate that the staff is correct?
1. “My mother was an alcoholic and neglected her family.”
2. “The client said I had the same disposition as his cranky wife.”
3. “Maybe the client and I can sit down and work out a plan.”
4. “The client refuses to accept responsibility for his alcoholism.”
1. In this example, countertransference refers to the nurse’s behavioral and emotional response to the client’s alcoholism. These feelings may be related to unresolved feelings toward significant others from the nurse’s past, or they may be generated in response to transference feelings on the part of the client. Intervention: Have evaluative sessions with the nurse after an encounter with the client, in which the nurse and staff members discuss and compare the exhibited behaviors in the nurse-client relationship. The relationship usually should not be terminated in the face of countertransference.
55. While talking about an abusive childhood, a client addicted to heroin suddenly blurts out, “I hate my doctor.” Which client statement would indicate that transference is taking place?
1. “The doctor has told me that his son recovered, and I will also.”
2. “I don’t care what anyone says, I don’t have a problem I can’t handle.”
3. “I’d bet my doctor beat and locked his son in a closet when he was a boy.”
4. “I’m going to stop fighting and start working together with my doctor.”
3. This is an example of transference which occurs when the client unconsciously displaces (or “transfers”) to the physician feelings formed toward a person from his or her past. Transference also can take the form of overwhelming affection with unrealistic expectations from the physician by the client. By accusing the doctor of abusing his son, the client is transferring his feelings of hate from the client’s father to the doctor. Intervention: The physician should work with the client to sort out the past from the present, identify the transference, and reassign a more appropriate meaning to the physician-client relationship.
1. A client states, “I don’t know what the pills are for or why I am taking them, so I don’t want them.” Which is an example of the therapeutic communication technique of “giving information”?
1. “You must take your medication to get better.”
2. “The doctor wouldn’t prescribe these pills if they were harmful.”
3. “Do you feel this way about all your medications?”
4. “Let me tell you about your medication.”
4. The nurse is offering to “give information” about the medications because the nurse has assessed from the client’s statement that information is needed.
2. A depressed client discussing marital problems with the nurse says, “What will I do if my husband asks me for a divorce?” Which response by the nurse would be an example of therapeutic communication?
1. “Why do you think that your husband will ask you for a divorce?”
2. “You seem to be worrying over nothing. I’m sure everything will be fine.”
3. “What has happened to make you think that your husband will ask for a divorce?”
4. “Talking about this will only make you more anxious and increase your depression.”
3. The therapeutic technique of “exploring,” along with reflective listening, draws out the client and can help the client feel valued, understood, and supported. Exploring also gives the nurse necessary assessment information to intervene appropriately.
3. A client states to the nurse, “I’m thinking about ending it all.” Which response by the nurse would be an example of therapeutic communication?
1. “I’m sure you won’t hurt yourself.”
2. “Wasn’t your wife just here during visiting hours?”
3. “Why would you want to do something like that?”
4. “You must be feeling very sad right now.”
4. This is the therapeutic technique of “attempting to translate words into feelings,” by which the nurse tries to find clues to the underlying true feelings and at the same time validates the client’s statement. The nurse might then explore and delve more deeply by responding, “Can you tell me more about this sadness you feel?”
4. Which statement is an example of the therapeutic communication technique “focusing”?
1. “You say you’re angry, but I notice that you’re smiling.”
2. “Are you saying that you want to drive to Hawaii?”
3. “Tell me again about Vietnam and your feelings after you were wounded.”
4. “I see you staring out the window. Tell me what you’re thinking.”
3. This is an example of the therapeutic communication technique of “focusing.” The nurse uses focusing to direct the conversation on a particular topic of importance or relevance to the client.
5. Which therapeutic communication exchange is an example of “reflection?”
1. Client: “I get sad because I know I’m going to fail in school.” Nurse: “So, you start feeling depressed every time a new semester begins?”
2. Client: “I forgot to get my prescription refilled.” Nurse: “It is important for you to take your medication as prescribed.”
3. Client: “I hate my recent weight gain.” Nurse: “Have you considered Overeaters Anonymous?”
4. Client: “I’m happy that I poisoned my husband.” Nurse: “You’re happy to have poisoned your husband?”
1. “Reflection” is used when directing back what the nurse understands in regard to the client’s ideas, feelings, questions, and content. Reflection is used to put the client’s feelings in the context of when or where they occur.
6. The nurse states to a client on an in-patient unit, “Tell me what’s been on your mind.” Which describes the purpose of this therapeutic communication technique?
1. To have the client initiate the conversation.
2. To present new ideas for consideration.
3. To convey interest in what the client is saying.
4. To provide time for the nurse and client to gather thoughts and reflect.
1. A “broad opening” helps the client initiate the conversation and puts the client in control of the content.
7. The nurse states to the client, “You say that you are sad, but you are smiling and laugh- ing.” Which describes the purpose of this therapeutic communication technique?
1. To provide suggestions for coping strategies.
2. To redirect the client to an idea of importance.
3. To bring incongruencies or inconsistencies into awareness.
4. To provide feedback to the client.
3. The nurse uses the therapeutic technique of “confronting” to bring incongruencies or inconsistencies into awareness.
8. Which is an example of the therapeutic communication technique of “clarification”?
1. “Can we talk more about how you feel about your father?”
2. “I’m not sure what you mean when you use the word ‘fragile.'”
3. “I notice that you seem angry today.”
4. “How does your mood today compare with yesterday?”
2. This example of “clarification” is an attempt by the nurse to check the nurse’s understanding of what has been said by the client and helps the client to make his or her thoughts or feelings more explicit.
9. The client states, “I’m not sure the doctor has prescribed the correct medication for my sad mood.” Which would be a therapeutic response?
1. “A lot of clients are nervous about new medications. I’ll get you some information
about it.”
2. “So you think that this medication is not right for you?”
3. “Why do you think that this medication won’t help your mood?”
4. “Your doctor has been prescribing this medication for years, and it really does help
people.”
2. By “verbalizing the implication” that the client thinks the medication is not good for the client’s problem, the nurse puts into words what the nurse thinks the client is saying. If the implication is incorrect, it gives the client an opportunity to clarify the statement further.
10. A client admitted for alcohol detoxification states, “I don’t think my drinking has any- thing to do with why I am here in the hospital. I think I have problems with depres- sion.” Which statement by the nurse is the most therapeutic response?
1. ” I think you really need to look at the amount you are drinking and consider the
effect on your family.”
2. “That’s wrong. I disagree with that. Your admission is because of your alcohol abuse
and not for any other reason.”
3. “I’m sure you don’t mean that. You have to realize that alcohol is the root of your
problems.”
4. “I find it hard to believe that alcohol is not a problem because you have recently lost
your job and your driver’s license.”
4. When using the therapeutic communication technique of “voicing doubt,” the nurse expresses uncertainty as to the reality of what is being communicated.
11. Delving further into a subject, idea, experience, or relationship is to “exploring” as taking notice of a single idea, or even a single word, is to:
1. “Broad opening.”
2. “Offering general leads.”
3. “Focusing.”
4. “Accepting.”
3. “Focusing” by the nurse allows the client to stay with specifics and analyze problems without jumping from subject to subject. Example: “Could we continue talking about your infidelity right now?”
12. Allowing the client to take the initiative in introducing the topic is to “broad opening” as the nurse’s making self available and presenting emotional support is to:
1. “Focusing.”
2. “Offering self.”
3. “Restating.”
4. “Giving recognition.”
2. “Offering self” by the nurse offers the client availability and emotional support. Example: “I’ll stay with you awhile.”
13. The nurse’s lack of verbal communication for therapeutic reasons is to “silence” as the nurse’s ability to process information and examine reactions to the messages received is to:
1. “Focusing.”
2. “Offering self.”
3. “Restating.”
4. “Listening.”
4. “Listening” by the nurse is the active process of receiving information and examining one’s reaction to the messages received. Example: Maintaining eye contact, open posture, and receptive nonverbal communication.
14. A client on an in-patient psychiatric unit asks the evening shift nurse, “How do you feel about my refusing to attend group therapy this morning?” The nurse responds, “How did your refusing to attend group make you feel?” Which communication technique is the nurse using in this situation?
1. Therapeutic use of “restatement.”
2. Nontherapeutic use of “probing.”
3. Therapeutic use of “reflection.”
4. Nontherapeutic use of “interpreting.”
3. “Reflection” therapeutically directs back to the client his or her ideas, feelings, questions, and content. Reflection also is a good technique to use when the client asks the nurse for advice.
15. A client on an in-patient psychiatric unit states, “My mother hates me. My father is a drunk. Right now I am homeless.” The nurse responds, “Let’s talk more about your feelings toward your mother” Which is a description of the technique used by the nurse?
1. The nurse uses questions or statements that help the client expand on a topic of
importance.
2. The nurse encourages the client to select a topic for discussion.
3. The nurse delves further into a subject or idea.
4. The nurse is persistent with the questioning of the client.
1. This is a description of “focusing,” which is the therapeutic technique presented in the question stem. Focusing can be helpful when clients have scattered thoughts, flight of ideas, or tangential thinking.
16. Which of the following are examples of therapeutic communication techniques? Select all that apply.
1. “Tell me about your drunk driving record.”
2. “How does this compare with the time you were sober?”
3. “That’s good. I’m glad that you think you can stop drinking.”
4. “I think we need to talk more about your previous coping mechanisms.” 5. “What led up to your taking that first drink after 5 sober years?”
2. This is an example of the therapeutic technique of “encouraging comparisons,” which asks that similarities and differences be noted.
4. This is an example of the therapeutic technique of “focusing,” which poses a statement that helps the client expand on a topic of importance.
5. This is an example of the therapeutic technique of “placing the event in time or sequence,” which clarifies the relationship of events in time so that the nurse and client can view them in perspective.
17. Which is an example of the therapeutic technique of “voicing doubt”?
1. “What I heard you say was . . . ?”
2. “I find that hard to believe.”
3. “Are you feeling that no one understands?”
4. “Let’s see if we can find the answer.”
2. This is an example of the therapeutic technique of “voicing doubt.” Voicing doubt expresses uncertainty as to the reality of the client’s perceptions and is often used with clients experiencing delusional thinking. Although it may feel uncomfortable, this is a necessary technique to present reality.
18. Indicating that there is no cause for anxiety is to “reassuring” as sanctioning or denouncing the client’s ideas or behaviors is to:
1. “Approving/disapproving.”
2. “Rejecting.”
3. “Interpreting.”
4. “Probing.”
1. “Approving/disapproving” implies that the
nurse has the right to pass judgment on whether the client’s ideas or behaviors are good or bad. Example: “That’s good. I’m glad that you . . . or “That’s bad. I’d rather you wouldn’t . . . .”
19. Demanding proof from the client is to “challenging” as persistent questioning of the client and pushing for answers the client does not wish to discuss is to:
1. “Advising.”
2. “Defending.”
3. “Rejecting.”
4. “Probing.”
4. Probing by the nurse involves persistently questioning the client and pushing for answers the client does not wish to reveal. Example: “Give me the details about your sexual abuse.”
20. Which is an example of the nontherapeutic technique of “giving reassurance?”
1. “That’s good. I’m glad that you. . . .”
2. “Hang in there, every dog has his day.”
3. “Don’t worry, everything will work out.”
4. “I think you should. . . .”
3. “Giving reassurance” is a nontherapeutic technique indicating there is no cause for client anxiety. This technique involves giving the client a false sense of confidence and devaluing the client’s feelings. It also may discourage the client from further expression of feelings if the client believes those feelings would only be downplayed or ridiculed.
21. Which is an example of the nontherapeutic technique of “requesting an explanation”?
1. “Who made you so angry last night?”
2. “Do you still have the idea that . . .?”
3. “How could you be dead, when you’re still breathing?”
4. “Why do you feel this way?”
4. . “Requesting an explanation” is a nontherapeutic technique that involves asking the client to provide reasons for thoughts, feelings, behaviors, and events. Asking why a client did something or feels a certain way can be intimidating and implies that the client must defend his or her behavior or feelings.
22. A client on a psychiatric unit says, “It’s a waste of time to be here. I can’t talk to you or anyone.” Which would be an appropriate therapeutic nursing response?
1. “I find that hard to believe.”
2. “Are you feeling that no one understands?”
3. “I think you should calm down and look on the positive side.”
4. “Our staff here is excellent, and you are in good hands.”
2. Putting into words what the client has only implied or said indirectly is “verbalizing the implied.” This clarifies that which is implicit rather than explicit by giving the client the opportunity to agree or disagree with the implication.
23. Which nurse-client communication-centered skill implies “respect”?
1. The nurse communicates regard for the client as a person of worth who is valued and
accepted without qualification.
2. The nurse communicates an understanding of the client’s world from the client’s
internal frame of reference, with sensitivity to the client’s current feelings, and the
ability to communicate this understanding in a language attuned to the client.
3. The nurse communicates that the nurse is an open person who is self-congruent,
authentic, and transparent.
4. The nurse communicates specific terminology rather than abstractions in the discus-
sion of the client’s feelings, experiences, and behaviors.
1. “Respect” is the responsive dimension that is characterized in this example. Respect suggests that the client is regarded as a person of worth who is valued and accepted without qualifications.
24. A client on a psychiatric unit tells the nurse, “I’m all alone in the world now, and I have no reason to live.” Which response by the nurse would encourage further communication by the client?
1. “You sound like you’re feeling lonely and frightened.”
2. “Why do you think that suicide is the answer to your loneliness?”
3. “I live by myself and know it can be very lonely and frightening.”
4. “Just hang in there and, you’ll see, things will work out.”
1. By understanding the client’s point of view, the nurse communicates empathy with regard to the client’s feelings. An empathic response communicates that the nurse is listening and cares, and encourages the client to continue communicating thoughts and feelings.
25. The nurse is attempting to establish a therapeutic relationship with an angry, depressed client on a psychiatric unit. Which is the most appropriate nursing intervention?
1. Work on establishing a friendship with the client.
2. Use humor to defuse emotionally charged topics of discussion.
3. Show respect that is not based on the client’s behavior.
4. Sympathize with the client when the client shares sad feelings.
3. Emotionally charged topics should be approached with respectful, sincere inter- actions. Therapeutic communication techniques are specific responses that encourage the expression of feeling or ideas and convey the nurse’s acceptance and respect.
26. On a substance abuse unit, a client diagnosed with cirrhosis of the liver tells the nurse, “I really don’t believe that my drinking a couple of cocktails a night has anything to do with my liver problems.” Which is the best nursing response?
1. “You find it hard to believe that drinking alcohol can damage the liver?”
2. “How long have you been drinking a couple of cocktails a night?”
3. “If not alcohol, explain how your liver became damaged.”
4. “It’s common knowledge that consuming alcohol continually over a long period of
time can damage the liver.”
1. Paraphrasing is restating another’s message more briefly using one’s own words. Through paraphrasing, the nurse sends feedback that lets the client know that the nurse is actively involved in the search for understanding.
27. In dealing therapeutically with a variety of psychiatric clients, the nurse knows that incorporating humor in the communication process should be used for which purpose?
1. To diminish feelings of anger.
2. To refocus the client’s attention.
3. To maintain a balanced perspective.
4. To delay dealing with the inevitable.
3. Humor is an interpersonal tool, is a healing strategy, and assists in maintaining a balanced perspective. The nurse’s goal in using humor is to bring hope and joy
to the situation and to enhance the client’s well-being and the therapeutic relationship.
28. Which nurse-client communication-centered skill implies “empathic understanding”? 1. The nurse communicates regard for the client as a person of worth who is valued and
accepted without qualification.
2. The nurse communicates an understanding of the client’s world from the client’s
internal frame of reference, with sensitivity to the client’s current feelings, and the
ability to communicate this understanding in a language attuned to the client.
3. The nurse communicates that the nurse is an open person who is self-congruent,
authentic, and transparent.
4. The nurse communicates specific terminology rather than abstractions in the discus-
sion of the client’s feelings, experiences, and behaviors.
2. “Empathetic understanding” is the responsive dimension that is characterized in this example. Empathetic understanding views the client’s world from the client’s internal frame of reference.
29. A client on an in-patient psychiatric unit has pressured speech and flight of ideas and is extremely irritable. During an intake assessment, which is the most appropriate nursing response?
1. “I think you need to know more about your medications.”
2. “What have you been thinking about lately?”
3. “I think we should talk more about what brought you into the hospital.”
4. “Yes, I see. And go on please.”
3. The nurse in this example is using the therapeutic communication technique of “focusing.” Focusing is an important facilitator when doing an assessment and when dealing with a client exhibiting flight of ideas.
30. A client in an out-patient clinic states, “I am so tired of these medications.” Which nursing response would encourage the client to elaborate further?
1. “I see you have been taking your medications.”
2. “Tired of taking your medications?”
3. “Let’s discuss different ways to deal with your problems.”
4. “How would your family feel about your stopping your medications?”
2. This is an example of “restating” and encourages the client to continue to talk about the topic being discussed. Restating lets the client know that the nurse has understood the expressed statement.
31. Which nurse-client communication-centered skill implies “genuineness”?
1. The nurse communicates regard for the client as a person of worth who is valued and
accepted without qualification.
2. The nurse communicates an understanding of the client’s world from the client’s
internal frame of reference, with sensitivity to the client’s current feelings, and the
ability to communicate this understanding in a language attuned to the client.
3. The nurse communicates that the nurse is an open person who is self-congruent,
authentic, and transparent.
4. The nurse communicates specific terminology rather than abstractions in the discus-
sion of the client’s feelings, experiences, and behaviors.
3. “Genuineness” is the responsive dimension that is characterized in this example.
32. A client diagnosed with major depression after a stroke has been admitted to the psychiatric unit. The report indicates that the client has special communication needs because of aphasia and dysarthria. Which communication adaptation technique by the nurse would be most helpful to this client?
1. Using simple sentences and avoiding long explanations.
2. Speaking to the client as though the client could hear.
3. Listening attentively, allowing time, and not interrupting.
4. Providing an interpreter (translator) as needed.
3. Clients who cannot speak clearly require special thought and sensitivity. When a client has aphasia and dysarthria, the nurse needs to listen intently, allow time, and not interrupt the client. Effective communication is critical to nursing practice.
33. A client who has been scheduled for electroconvulsive therapy (ECT) in the morning tells the nurse, “I’m really nervous about having ECT tomorrow.” Which would be the best nursing response?
1. “I’ll ask the doctor for a little medication to help you relax.”
2. “It’s okay to be nervous. What are your concerns about the procedure?”
3. “Clients who have had ECT say there’s nothing to it.”
4. “Your doctor is excellent and has done hundreds of these procedures.”
2. This response recognizes the client’s feelings of nervousness and encourages more communication with regard to the ECT procedure itself.
34. An instructor overhears the nursing student ask a client, “This is your third admission. Why did you stop taking your medications?” Which statement by the instructor would be appropriately related to the student’s question?
1. “Your question implied criticism and could have the effect of making the client feel
defensive.”
2. “Your question invited the client to share thoughts and feelings regarding the client’s
noncompliance.”
3. “Your question recognized and acknowledged the client’s reasons for his or her
actions.”
4. “Your question pursued the topic to make the client’s intentions clear.”
1. “Why” questions put the nurse in the role
of an interrogator, demanding information without respect for the client’s readiness or willingness to respond. It would be better to say, “Tell me about your concerns regarding your medications.”
35. The nurse’s focus on client behavior rather than on the client himself or herself is one of the many strategies of nonthreatening feedback. What is the reason for using this particular strategy?
1. This strategy reports what occurred, rather than evaluating it in terms of right or
wrong or good or bad.
2. This strategy refers to what the client actually does, rather than how the nurse perceives the client to be.
3. This strategy refers to a variety of alternatives for accomplishing a particular objective and impedes premature acceptance of solutions or answers that may not be
appropriate.
4. This strategy implies that the most crucial and important feedback is given as soon as it is appropriate to do so.
2. This is the correct rationale for this strategy. Feedback is descriptive rather than evaluative and focuses on the client’s behavior, rather than on how the nurse conceives the client to be. When the focus is on the client, and not the behavior, the nurse may make judgments about the client. “Feedback” is a method of communication for helping the client consider a modification of behavior and gives information to clients about how they are perceived by others.
36. When the nurse focuses on a client’s specific behavior rather than on the client himself or herself, the nurse is using a strategy of nonthreatening feedback. Which nursing statement is an example of this strategy?
1. “It’s okay to be angry, but throwing the book was unacceptable behavior.”
2. “I can’t believe you are always this manipulative.”
3. “You are an irresponsible person regarding your life choices.”
4. “Asking for meds every 2 hours proves you are drug seeking.”
1. When the nurse focuses on the client’s behavior versus assumptions about the client, the nurse gives nonthreatening feedback, facilitating the communication process.
37. The nurse understands that one of the many strategies of nonthreatening feedback is to limit the feedback to an appropriate time and place. While in the milieu, which nursing statement is an example of this strategy?
1. “Let’s talk about your marital concerns in the conference room after visiting hours.”
2. “I know your mother is visiting you, but I need answers to these questions.”
3. “Why don’t we talk about your childhood sexual abuse?”
4. “Let’s talk about your grievance with your doctor during group.”
1. Providing a private place and adequate time for successful interactions is essential to nonthreatening feedback.
38. Which nurse-client communication-centered skill implies “correctness”?
1. The nurse communicates regard for the client as a person of worth who is valued and
accepted without qualification.
2. The nurse communicates an understanding of the client’s world from the client’s
internal frame of reference, with sensitivity to the client’s current feelings, and the
ability to communicate this understanding in a language attuned to the client.
3. The nurse communicates that the nurse is an open person who is self-congruent,
authentic, and transparent.
4. The nurse communicates specific terminology rather than abstractions in the discus-
sion of the client’s feelings, experiences, and behaviors.
4. “Correctness” is the responsive dimension that is characterized in this example.
39. To understand and participate in therapeutic communication, the nurse must under- stand which of the following? Select all that apply.
1. More than half of all messages communicated are nonverbal.
2. All communication is best accomplished in a “social” space context.
3. Touch is always a positive form of communication to convey warmth and caring.
4. The physical space between two individuals has great meaning in the communication process.
5. The use of silence never varies across cultures.
1. “Nonverbal communication” refers to all of the messages sent by other than verbal or written means. It is estimated that more than half of all messages communicated are nonverbal, which include behaviors, cues, and presence.
4. The physical space between two individuals has great meaning in the communication process. Space between two individuals gives a sense of their relationship and is linked to cultural norms and values.
40. A nurse is communicating with a client on an in-patient psychiatric unit. The client moves closer and invades the nurse’s personal space, making the nurse uncomfortable. Which is an appropriate nursing intervention?
1. The nurse ignores this behavior because it shows the client is progressing.
2. The nurse expresses a sense of discomfort and limits behaviors.
3. The nurse understands that clients require various amounts of personal space and
accepts the behavior.
4. The nurse confronts and informs the client that the client will be secluded if this
behavior continues.
2. The nurse should express feelings of discomfort and ask the client to move back. If the nurse allows the client to invade the nurse’s personal space, the nurse has missed the opportunity to role-play appropriate interpersonal boundaries
41. A client on a psychiatric unit is telling the nurse about losing an only child in a plane crash and about anger toward the airline. In which situation is the nurse demonstrating active listening?
1. Agreeing with the client.
2. Repeating everything the client says to clarify.
3. Assuming a relaxed posture and leaning toward the client.
4. Expressing sorrow and sadness regarding the client’s loss.
3. Active listening does not always require a response by the nurse. Body posture and facial expression may be all that are required for the client to know that the nurse is listening and interested in what is going on with the client.
42. The place where communication occurs influences the outcome of the interaction. Which of the following are aspects of the environment that communicate messages? Select all that apply.
1. Dimension.
2. Distance.
3. Territoriality.
4. Volume.
5. Density.
2. “Distance” is the means by which various cultures use space to communicate. The following are four kinds of distances: intimate distance, personal distance, social distance, and public distance.
3. “Territoriality” influences communication when an interaction occurs in the territory “owned” by one or the other. For example, a nurse may choose to conduct a psychosocial assessment in an interview room as opposed to the client’s room.
4. Increased noise volume in the environment can interfere with receiving accurate incoming verbal messages.
5. “Density” refers to the number of people within a given environmental space and has been shown to influence interaction. Some studies show that high density is associated with aggression, stress, crimi- nal activity, and hostility toward others.
32. Which of the following are examples of anticholinergic side effects from tricyclic anti- depressants? Select all that apply.
1. Urinary hesitancy.
2. Constipation.
3. Blurred vision.
4. Sedation.
5. Weight gain.
1. Urinary hesitancy is an anticholinergic
side effect.
2. Constipation is an anticholinergic side
effect.
3. Blurred vision is an anticholinergic side
effect.
35. Which situation would place a client at high risk for a life-threatening hypertensive crisis?
1. A client is prescribed tranylcypromine (Parnate) and eats chicken salad.
2. A client is prescribed isocarboxazid (Marplan) and drinks hot chocolate.
3. A client is prescribed venlafaxine (Effexor) and drinks wine.
4. A client is prescribed phenelzine (Nardil) and eats fresh roasted chicken.
2. Isocarboxazid is an MAOI, and the intake of chocolate would cause a life-threatening hypertensive crisis.
38. A client on an in-patient psychiatric unit has been prescribed tranylcypromine (Parnate) 30 mg QD. Which client statement indicates that discharge teaching has been successful?
1. “I can’t wait to order liver and fava beans with a nice Chianti.”
2. “Chicken teriyaki with soy sauce, apple sauce, and tea sound great.”
3. “I have been craving a hamburger with lettuce and onion, potato chips, and milk.”
4. “For lunch tomorrow I’m having bologna and cheese, a banana, and a cola.”
3. All of the foods chosen in this meal are safe to ingest when taking an MAOI.
39. A client recently prescribed venlafaxine (Effexor) 37.5 mg bid complains of dry mouth, orthostatic hypotension, and blurred vision. Which nursing intervention is appropriate?
1. Hold the next dose, and document symptoms immediately.
2. Reassure the client that side effects are transient, and teach ways to deal with them.
3. Call the physician to receive an order for benztropine (Cogentin).
4. Notify the dietary department about restrictions related to monoamine oxidase inhibitors.
2. The nurse needs to teach the client about acceptable side effects, and what the client can do to deal with them. The nurse can suggest that the client use ice chips, sip small amounts of water, or chew sugar-free gum or candy to moisten the dry mouth. For orthostatic hypotension, the nurse may encourage the client to change positions slowly.
40. A client comes to the hospital complaining of depression with suicidal ideations. The physician prescribes citalopram (Celexa). Approximately 4 days later, the client has pressured speech and is noted wearing heavy makeup. What may be a potential reason for this client behavior?
1. The client is in a manic episode caused by the citalopram (Celexa).
2. The client is showing improvement and is close to discharge.
3. The client is masking depression in an attempt to get out of the hospital.
4. The client has “cheeked” medications and taken them all at once in an attempt to
overdose.
1. When an SSRI is prescribed for clients with bipolar affective disorder, it can cause alterations in neurotransmitters and trigger a hypomanic or manic episode.
42. A client prescribed lithium carbonate (lithium) 300 mg QAM and 600 mg QHS enters the emergency department experiencing impaired consciousness, nystagmus, and arrhythmias. Earlier today the client had two seizures. Which serum lithium level would the nurse expect to assess?
1. 3.7 mEq/L.
2. 3.0 mEq/L.
3. 2.5 mEq/L.
4. 1.9 mEq/L.
1. Clients with a serum level greater than 3.5 mEq/L may show signs such as impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, or cardiovascular collapse.
43. A client is newly prescribed lithium carbonate (lithium). Which teaching point by the nurse takes priority?
1. “Make sure your salt intake is consistent.”
2. “Limit your fluid intake to 2000 mL/day.”
3. “Monitor your caloric intake because of potential weight gain.”
4. “Get yourself in a daily routine to assist in avoiding relapse.”
1. Lithium is similar in chemical structure to sodium, behaving in the body in much the same manner and competing with sodium at various sites in the body. If sodium intake is reduced, or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, and this increases the potential for toxicity.
44. Which list contains medications that the nurse may see prescribed to treat clients diagnosed with bipolar affective disorder?
1. Lithium carbonate (lithium), loxapine (Loxitane), and carbamazepine (Tegretol).
2. Gabapentin (Neurontin), thiothixene (Navane), and clonazepam (Klonopin).
3. Divalproex sodium (Depakote), verapamil (Calan), and olanzapine (Zyprexa).
4. Lamotrigine (Lamictal), risperidone (Risperdal), and benztropine (Cogentin).
3. Divalproex sodium (Depakote), an anticon- vulsant, and verapamil (Calan), a calcium channel blocker, are used in the long-term treatment of BPAD. Olanzapine (Zyprexa), an antipsychotic, has been approved by the Food and Drug Administration for the treatment of acute manic episodes.
45. The nurse is evaluating lab test results for a client prescribed lithium carbonate (lithium). The client’s lithium level is 1.9 mEq/L. Which nursing intervention takes priority?
1. Give next dose because the lithium level is normal for acute mania.
2. Hold the next dose, and continue the medication as prescribed the following day.
3. Give the next dose after assessing for signs and symptoms of lithium toxicity.
4. Immediately notify the physician, and hold the dose until instructed further.
4. The nurse needs to notify the physician immediately of the serum level, which is outside the therapeutic range, to avoid any risk for further toxicity.
46. A client prescribed lithium carbonate (lithium) 300 mg bid 3 months ago is brought into the hospital emergency department with mental confusion, excessive diluted urine output, and consistent tremors. Which lithium level would the nurse expect?
1. 1.2 mEq/L.
2. 1.5 mEq/L.
3. 1.7 mEq/L.
4. 2.2 mEq/L.
4. When the serum lithium level is 2.0 to 3.5 mEq/L, the client may exhibit signs such as excessive output of diluted urine, increased tremors, muscular irritability, psychomotor retardation, mental confusion, and giddiness.
48. A client diagnosed with bipolar affective disorder is prescribed divalproex sodium (Depakote). Which of the following lab tests would the nurse need to monitor throughout drug therapy? Select all that apply.
1. Platelet count and bleeding time.
2. Aspartate aminotransferase (AST).
3. Fasting blood sugar (FBS).
4. Alanine aminotransferase (ALT).
5. Valproic acid level.
1. Platelet counts and bleeding times need to
be monitored before and during therapy with divalproex sodium (Depakote) because of the potential side effects of blood dyscrasias and prolonged bleeding
time.
2. Aspartate aminotransferase is a liver enzyme test that needs to be monitored before and during therapy with divalproex sodium (Depakote) because of the potential side effect of liver toxicity.
49. A client diagnosed with bipolar affective disorder is prescribed carbamazepine (Tegretol). The client exhibits nausea, vomiting, and anorexia. Which is an appropri- ate nursing intervention at this time?
1. Stop the medication, and notify the physician.
2. Hold the next dose until symptoms subside.
3. Administer the next dose with food.
4. Ask the physician for a stat carbamazepine (Tegretol) level.
3. When clients prescribed carbamazepine (Tegretol) experience nausea, vomiting, and anorexia, it is important for the nurse to administer the medication with food to decrease these uncomfortable, but acceptable, side effects. If these side effects do not abate, other interventions may be necessary.
42. A client prescribed lithium carbonate (lithium) 300 mg QAM and 600 mg QHS enters the emergency department experiencing impaired consciousness, nystagmus, and arrhythmias. Earlier today the client had two seizures. Which serum lithium level would the nurse expect to assess?
1. 3.7 mEq/L.
2. 3.0 mEq/L.
3. 2.5 mEq/L.
4. 1.9 mEq/L.
1. Clients with a serum level greater than 3.5 mEq/L may show signs such as impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, or cardiovascular collapse
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