Psychiatric Nursing Midterm Practice Questions - Flashcards

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Discontinuation Syndrome

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Antidepressant discontinuation syndrome is a condition that can occur following the interruption, dose reduction, or discontinuation of antidepressant drugs, including selective serotonin re-uptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs)

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Symptoms of discontinuation syndrome?

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Dizziness, vertigo or ataxia (problems with muscle coordination) Paresthesia (tingling or pricking of your skin), numbness, electric-shock-like sensations Lethargy, headache, tremor, sweating or anorexia Insomnia, nightmares or excessive dreaming Nausea, vomiting or diarrhea Irritability, anxiety, agitation or low mood

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Serotonin Syndrome

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-Group of symptoms that may occur following use of certain serotonergic medications or drugs; symptoms include high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea. -Discontinue drug immediately, monitor vital signs, cooling blankets, safety measures to prevent injury from muscle rigidity and spasms

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Substances high in tyramine

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coffee tea wine beer chocolate beef chicken liver canned figs cold remedies

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Neuroleptic Malignant Syndrome

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-Can occur in individuals on antipsychotics -Hyperexia: cooling blanket! -Muscle rigidity due to autonomic hyperactivity -Rapid deterioration of mental status -Acute reduction in brain dopamine plays role in NMS development

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ECT: Atropine Sulfate?

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Decrease secretions and increase heart rate

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ECT: Methohexital Sodium and Succinylcholine

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induce anesthesia and relax muscles

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ECT: "I feel so much better but im having trouble remembering some things that happened last week"

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Memory loss is a side effect of ECT, but it is only temporary. Your memory should return in a few weeks.

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ECT Patient Preparation

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-Encourage patient to express any fears -Discuss the possibility of short term memory loss -Monitor for any cardiac alterations to avoid possible negative outcomes

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Apraxia

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Person is unable to perform tasks or movements when asked even though the command or request is understood

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Ataxia

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Loss of full control of body movements; loss of voluntary coordination of muscle movements

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Akathisia

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a state of agitation, distress, and restlessness that is an occasional side-effect of antipsychotic and antidepressant drugs.

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Phases of Treatment and Recovery of Depression

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Acute Continuation Maintenance

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Acute Phase of Depression Tx

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6-12 weeks; directed at reduction of symptoms and restoration of psychosocial and work function; takes 2-4 weeks for most antidepressants to begin being noticeably effective

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Continuation Phase of Depression Tx

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4-9 months; generally treated for 9 mos before titration and discharge of meds are clinically considered; directed at prevention of relapse through meds, education and depression-specific psychotherapy

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Maintenance Phase of Depression Tx

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1 year or more; treatment directed at prevention of further episodes of depression

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Flooding

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Form of behavior therapy based on the principles of respondent conditioning. It is sometimes referred to as exposure therapy or prolonged exposure therapy. As a psychotherapeutic technique, it is used to treat phobia and anxiety disorders including post-traumatic stress disorder; putting them through their trauma and not letting leave

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Systematic Desensitization

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Teach person how to relax and then gradually get them to face the fear first mentally and then physically

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Cognitive Behavioral Therapy

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-Fix faulty thinking/cognitive distortion -8-12 weeks

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What is buspirone a good treatment for?

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GAD

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Depersonalization

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An alteration in the perception or experience of the self so that the feeling of ones own reality is temporarily lost

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Derealization

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Alteration in the perception or experience of the external world so that it seems strange or unreal

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Benzodiazepines

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lorazepam prazepam flurazepam quazepam triazolam clonazepam chlordiazepoxide halazepam temazepam oxazepam clorazepate diazepam midazolam alprazolam

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MAOIs

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-Wash out for 2 weeks if switching meds -Phenalzine (Nardil)

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TCAs

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4-8 weeks for full effect -Blurred vision, constipation, urinary retention, orthostatic hypotension, reduction of seizure threshold, cardiac issues, photosensitivity, weight gain -Type of heterocyclic

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Cluster A PD

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-Paranoid -Schizoid -Schizotypal -"mad" -Withdrawn and distrustful; do not seek help -Difficulty relating to others, isolate -antipsychotics for psychotic decompensation

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Cluster B PD

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-Narcissistic -Historionic -Borderline (SSRI & MAOIs decreasing destructive acts; antipsychotics for psychotic decompensation) -Antisocial (lithium & inderal for violent episodes) -"bad" -High incidence found in prisons -Little to no insight into own behaviors

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Cluster C PD

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-Obsessive Compulsive -Avoidant (anxiolytics) -Dependant -"sad"

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Medical Morbidities Associated with Anxiety

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Hyperthyroidism, patients tapered off of steroids, etc.

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Primary Brain Structures Related to Anxiety

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Hippocampus and amygdala

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ECT

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temporary memory loss, confusion, acutely suicidal pt, severely depressed pt, etc.

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Lithium Therapeutic Range: Acute Mania

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1-1.5

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Lithium Therapeutic Range: Maintenance

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0.6-1.2

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Lithium

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-Prevents and treats manic episodes -Contraindicated in cardiac or renal disease, dehydration, sodium depletion, brain damage, pregnancy and lactation

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Bipolar Treatment

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Individual therapy, group and family therapy, cognitive and psychopharmacology -Most effective tx is combo of psychotropic med and psychosocial therapy

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Signs of Lithium Toxicity

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-Persistent nausea -Vomiting -Severe diarrhea -Weakness -Ataxia -Blurred vision -Excessive output of urine -Increased tremors -Diaphoresis -Mental confusion

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Anxiety NT's

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Increased NE Decreased GABA Decreased Serotonin

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Depression NT's

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Decrease serotonin, NE, dopamine

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Antidepressant Action

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block reuptake of serotonin & ne

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Antipsychotic Action

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block dopamine NT receptor

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Benzo Action

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Facilitate transmission of GABA

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Psychostimulants

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increase release of NE, serotonin, dopamine

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Schizophrenic Mania NT's

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Increased dopamine

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Alzhemiers NT's

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Decreased acetylcholine

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Mood Disorder NT's

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Increased serotonin, NE, and dopamine

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Highest Suicide Risk?

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-panic disorder pt -GAD and OCD also have high risk

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Primary Anxiolytics Action

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Depress CNS, particularly limbic system benzos potentiate gaba mild sedation

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Buspirone Action

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doesnt depress CNS, produces effect with 5Ht, DA, and other NT's

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Acute Toxicity of Benzo

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somnolence, confusion, diminished reflex, coma

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Benzo Overdose Treatment

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Flumazenil/Romazicon; benzo antagonist

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Panic Disorder First Line Tx

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SSRI/SNRI

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GAD First Line Tx

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SSRI/SNRI

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Agoraphobia Tx

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TCA, MAOI

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OCD First Line Tx

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SSRI

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Trichotillomania Tx

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-SSRIs + Pimozide (Typical) -Olanzapine (Atypical) -Chlorpromazine (Typical) -Amitriptyline (TCA) -Lithium (Mood Stabilizer)

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Anxiolytic Precautions

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-Orthostatic hypotension -Risk of seizures with abrupt discontinuation -Risk of interactions with other CNS depressants -Addiction -TCAs have greater side effects than SSRIs -MAOIs have the most side effects; dietary interaction concerns -SSRIs side effects are usually transient; sleep disturbances,

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PTSD

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>1 month of symptoms

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Acute Stress Disorder

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</=1 month

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Adjustment Disorder

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Occur within 3 months of stressor

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Side Effects That Occur With All Classes

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-dry mouth, sedation, nausea, discontinuation syndrome

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Trauma First Line Tx

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SSRI

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MDD

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Symptoms > 2 weeks worst in morning better as day goes on thoughts of death

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Dysthymia

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2 years or greater feeling like shit most of the time feels best in AM and worse as day goes on

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Heterocyclics

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Buproprion Trazodone Nefazodone Mirtazine

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What severe side effect can occur if patient on MAOIs consumes tyramine?

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Hypertensive crisis because tyramine cannot be destroyed in the liver; discontinue drug immediately, use cooling blanket, give short acting antihypertensive med

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Which of the following parts of the brain is associated with multiple feelings and behaviors and is sometimes referred to as the emotional brain?

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Limbic system

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What part of the brain is associated with visual reception and interpretation?

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Occipital lobe

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Schizophrenia Positive Symptoms

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Delusions, hallucinations, psychotic symptoms

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Schizophrenia Negative Symptoms

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-Affect (bland, flat, inappropriate) -Volitions (emotional ambivalence, deteriorated appearance) -Psychomotor behavior (Anergia, waxy flexibility, posturing, pacing, rocking), anhedonia, regression -Hard to define, they are buried, comes later, once and individual gets treatment for delusions and hallucinations

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A client is experiencing pain that has no organic etiology. This pain allows the client to avoid going to work at a job he hates. What best describes what this client is experiencing? a) Altered social interaction b) Disturbed thought processes c) Primary gain d) Secondary gain

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c) primary gain

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While a client is taking alprazolam/Xanax, which of the following should the nurse instruct the client to avoid? a) Chocolate b) Cheese c) Alcohol d) Shellfish

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c) alcohol

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Which of the following is the most appropriate initial nursing intervention? a) Call the doctor to report the incident b) Stay with Ms. T until the anxiety has subsided c) Administer prn alprazolam/Xanax d) Allow her some privacy to work through the emotions

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b) Stay with Ms. T until the anxiety has subsided

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When working with a client diagnosed with a somatic symptom disorder, which is the most appropriate nursing action? a) Avoid discussing social and personal problems b) Focus on the physical symptoms c) Always meet the client's dependency needs d) Gradually minimize time focusing on physical symptoms

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d) Gradually minimize time focusing on physical symptoms

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According to psychodynamic theory, which primary defense mechanism would the nurse expect to find in a client with dissociative amnesia? a) Suppression b) Sublimation c) Displacement d) Repression

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d) repression

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What should the nurse plan to teach a client who is taking alprazolam (Xanax) three times a day? a) That there is a potential for dependence and tolerance. b) The importance of discontinuing Xanax immediately if addiction is suspected. c) That increased caffeine consumption can enhance the effectiveness of Xanax d) That Xanax is not habit forming.

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a) That there is a potential for dependence and tolerance.

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A client, experiencing lower extremity paralysis, is admitted to a medical unit. Extensive tests confirm disability but rule out any underlying organic pathology. The nurse concludes that this is most suggestive of which disorder? a) Conversion disorder b) Illness anxiety disorder c) Malingering d) Somatic symptom disorder

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a) conversion disorder

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The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. The nurse should first: a)Request that the client's discharge be cancelled. b)Ignore the client's statement because it's a sign of manipulation. c)Ask a family member to stay with the client at home temporarily. d)Discuss the meaning of the client's statement with her.

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d)Discuss the meaning of the client's statement with her.

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When caring for a client who is experiencing a panic attack, which of the following nursing actions should be implemented? a) Leave the client alone to maintain privacy. b) Instruct the client regarding unit rules and regulations. c) Sit with the client in the day room to provide comfort. (should not be in the day room, it is too stimulating) d) Communicate with simple words and brief messages.

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d Communicate with simple words and brief messages.

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Which of the following medications is considered to be a first-line medication of choice in the treatment of PTSD? a) alprazolam/Xanax b) Propranolol c) carbamazepine/Tegretol (antiseizure, treats mood disorders) d) paroxetine/Paxil (SSRIs)

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d) paroxetine/Paxil (SSRIs)

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For the last year, a college student continually and unrealistically worries about academic performance and love life performance. The student is irritable and suffers from severe insomnia. This behavior is associated with which diagnosis? a) Agoraphobia b) Generalized anxiety disorder (GAD) c) Social phobia disorder d) Obsessive-compulsive disorder (OCD)

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b) Generalized anxiety disorder (GAD)

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A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), spends 1 hour packing and unpacking, folding and refolding personal belongings. What is the most likely reason for this behavior? a) It relieves anxiety. b) It fosters organizational skills. c) It delays meeting unfamiliar people in the dayroom d) It makes the client feel good.

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a) It relieves anxiety.

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When teaching about the tricyclic group of antidepressant medications, which information should the nurse include? a) Strong or aged cheese should not be eaten while taking this group of medications b) The full therapeutic potential of tricyclics may not be reached for 4 weeks. c) Long-term use may result in physical dependence. d) Tricyclics should not be given with anti-anxiety agents.

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b) The full therapeutic potential of tricyclics may not be reached for 4 weeks.

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A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: a) Suggesting a reduction in medication b) Allowing increased "in room" activities c) Increasing the level of suicide precautions d) Allowing the client off-unit privileges as needed.

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c) Increasing the level of suicide precautions

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A client, with a history of a suicide attempt, has been discharged and is being followed in an outpatient clinic. At this time, which is the most appropriate nursing intervention for this client? a) Provide the client with a safe and structured environment. b) Isolate the client from all stressful situations that may precipitate a suicide attempt. c) Observe the client continuously to prevent self-harm. d) Assist the client to develop more effective coping mechanisms.

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d) Assist the client to develop more effective coping mechanisms.

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The nurse is caring for an actively suicidal client on the psychiatric unit. What is the nurse's priority intervention? a) Discuss strategies for the management of anxiety, anger, and frustration. b) Provide opportunities for increasing the client's self-worth, morale, and control. c) Place client on suicide precautions with one-to-one observation. d) Explore experiences that affirm self-worth and self-efficacy.

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c) Place client on suicide precautions with one-to-one observation.

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In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? a) Risk for injury related to excessive hyperactivity b) Disturbed sleep pattern related to manic hyperactivity c) Imbalanced nutrition, less than body requirements, related to inadequate intake d) Situational low self-esteem related to embarrassment secondary to high-risk behaviors

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a) Risk for injury related to excessive hyperactivity

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A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asked the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will... a) Outline methods for managing anger b) Control impulsive actions towards self and others c) Verbalize feelings when anger occurs d) Recognize consequences for behaviors exhibited

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b) Control impulsive actions towards self and others

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A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? a) Do not skimp on dietary sodium intake b) Have serum lithium levels checked every 6 months c) Limit fluid intake to 1,000 ml of fluid per day d) Adjust the dose if you feel out of control

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a) Do not skimp on dietary sodium intake

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A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? 1. Assess for medication nonadherance. 2. Note escalating behaviors and intervene immediately. 3. Interpret attempts at communication. 4. Assess triggers for bizarre, inappropriate behaviors

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ANS: 2 Rationale: The nurse should note escalating behaviors and intervene immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

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A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? 1. The side effects of medications 2. Deep breathing techniques to decrease stress 3. How to make eye contact when communicating 4. How to be a leader

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ANS: 3 Rationale: The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships.

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A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response? 1. "Your child has a chemical imbalance of the brain, which leads to altered perceptions." 2. "Your child's hallucinations are caused by medication interactions." 3. "Your child has too little serotonin in the brain, causing delusions and hallucinations." 4. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

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ANS: 1 Rationale: The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. Hallucinations, or false sensory perceptions, may occur in all five senses. The client hearing voices is experiencing an auditory hallucination.

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Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response? 1. "Tell him to stop discussing the voices." 2. "Ignore what he is saying, while attempting to discover the underlying cause." 3. "Focus on the feelings generated by the hallucinations and present reality." 4. "Present objective evidence that the voices are not real."

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ANS: 3 Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception.

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A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1. Thought insertion 2. Paranoid delusions 3. Magical thinking 4. Delusions of reference

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ANS: 4 Rationale: The nurse is assessing for the potential symptom of delusions of reference. A client that believes he or she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward him- or herself.

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A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? 1. "Did you take your medicine this morning?" 2. "You are not going to hell. You are a good person." 3. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." 4. "The devil only talks to people who are receptive to his influence."

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ANS: 3 Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that "the voices" are a part of the illness is a way to help the client accept that the hallucinations are not real. It is also important for the nurse to connect with the client's fears and inner feelings.

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A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client? 1. Disturbed sensory perception 2. Altered thought processes 3. Risk for violence: directed toward others 4. Risk for injury

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ANS: 3 Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

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Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder? 1. Provide neon lights and soft music. 2. Maintain continual eye contact throughout the interview. 3. Use therapeutic touch to increase trust and rapport. 4. Provide personal space to respect the client's boundaries.

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ANS: 4 Rationale: The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence.

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Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1. Establishing personal contact with family members 2. Being reliable, honest, and consistent during interactions 3. Sharing limited personal information 4. Sitting close to the client to establish rapport

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ANS: 2 Rationale: The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

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A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? 1. Magical thinking; administer an antipsychotic medication. 2. Persecutory delusions; orient the client to reality. 3. Command hallucinations; warn the psychiatrist. 4. Altered thought processes; call an emergency treatment team meeting

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ANS: 3 Rationale: The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. Clients demonstrating a risk for violence could potentially be physically, emotionally, and/or sexually harmful to others or to self.

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A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? 1. Tactile hallucinations 2. Tardive dyskinesia 3. Restlessness and muscle rigidity 4. Reports of hearing disturbing voices

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ANS: 3 Rationale: The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

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A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. 4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia

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ANS: 2 Rationale: The nurse should recognize that positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include, but are not limited to, flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a diminution or loss of normal functions

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A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client? 1. Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications 2. Agranulocytosis treated by administration of clozapine (Clozaril) 3. Extrapyramidal symptoms treated by administration of benztropine (Cogentin) 4. Tardive dyskinesia treated by discontinuing antipsychotic medications

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ANS: 4 Rationale: The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medication. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be a side effect of typical antipsychotic medications.

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After taking chlorpromazine (Thorazine) for 1 month, a client presents to an ED with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client? 1. Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium) 2. Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication 3. Dystonia treated by administering trihexyphenidyl (Artane) 4. Dystonia treated by administering bromocriptine (Parlodel)

answer

ANS: 1 Rationale: The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine and administering dantrolene. Neuroleptic malignant syndrome is a potentially fatal condition characterized by rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics because they have fewer side effects and present a lower risk.

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A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize? 1. Respirations of 22 beats/minute 2. Weight gain of 8 pounds in 2 months 3. Temperature of 104F (40C) 4. Excessive salivation

answer

ANS: 3 Rationale: When assessing a client diagnosed with schizophrenia spectrum disorder who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high may indicate neuroleptic malignant syndrome, a life-threatening side effect of antipsychotic medications.

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An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

answer

ANS: 3 Rationale: The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension

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A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention

answer

ANS: 1 Rationale: The nurse should intervene immediately if the client experiences signs of an infectious process, such as a sore throat, fever, and malaise, when taking the atypical antipsychotic drug clozapine. Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur, leading to infection

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During an admission assessment, a nurse assesses that a client diagnosed with schizophrenia spectrum disorder has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? 1. Haloperidol (Haldol), because it is used only in older patients 2. Clozapine (Clozaril), because it is incompatible with desipramine 3. Risperidone (Risperdal), because it exacerbates symptoms of depression 4. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

answer

ANS: 4 Rationale: The nurse should know that thioridazine would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine and thioridazine are both classified as phenothiazines

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A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis? 1. The client has experienced impaired reality testing for a 24-hour period. 2. The client has experienced auditory hallucinations for the past 3 hours. 3. The client has experienced bizarre behavior for 1 day. 4. The client has experienced confusion for 3 weeks.

answer

ANS: 2 Rationale: This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month.

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A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client's symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)? 1. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not. 2. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not. 3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features. 4. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.

answer

ANS: 3 Rationale: The diagnosis of SIPD is made when symptoms are directly attributable to substance intoxication or withdrawal. The symptoms are more excessive and more severe than those usually associated with the intoxication or withdrawal syndrome. Hallucinations and delusions are associated with both SIPD and BPD. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.

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A nurse prepares to assess a client using the Abnormal Involuntary Movement Scale (AIMS). Which side effect of antipsychotic medications led to the use of this assessment tool? 1. Dystonia 2. Tardive dyskinesia 3. Akinesia 4. Akathisia

answer

ANS: 2 Rationale: The AIMS is a rating scale that was developed in the 1970s by the National Institute of Mental Health to measure involuntary movements associated with tardive dyskinesia

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Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

answer

ANS: 1, 2, 4, 5 Rationale: The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part of rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort

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A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would most likely decrease because of the therapeutic effect of this medication? (Select all that apply.) 1. Somatic delusions 2. Social isolation 3. Gustatory hallucinations 4. Flat affect 5. Clang associations

answer

ANS: 1, 3, 5 Rationale: The nurse should expect that risperidone would be effective treatment for the positive symptoms of somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms

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Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would a nurse expect to observe during assessment? (Select all that apply.) 1. Apathy 2. Social withdrawal 3. Anhedonia 4. Auditory hallucinations 5. Delusions

answer

ANS: 1, 2, 3 Rationale: The nurse should expect that a client with decreased levels of prolactin may experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression, which could result in these symptoms.

question

The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.) 1. Hyperthyroidism2. Hypothyroidism 3. Hyperadrenalism 4. Hypoadrenalism 5. Hyperaphia

answer

ANS: 1, 2, 3, 4 Rationale: The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders (e.g., hepatic encephalopathy, hypo- and hyperthyroidism, hypo- and hyperadrenalism, and vitamin B12 deficiency) and neurological conditions (e.g., epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis). Hyperaphia is an excessive sensitivity to touch

question

26. Order the spectrum of schizophrenic and other psychotic disorders as described by the DSM-5 on a gradient of psychopathology from least to most severe. ________ Delusional disorder ________ Schizotypal personality disorder ________ Schizophrenia ________ Brief psychotic disorder ________ Psychotic disorder associated with another medical condition ________ Catatonic disorder associated with another medical condition ________ Schizoaffective disorder ________ Schizophreniform disorder ________ Substance-induced psychotic disorder

answer

ANS: The correct order is 2, 1, 9, 3, 5, 6, 8, 7, 4 Rationale: A spectrum of schizophrenic and other psychotic disorders has been identified in the DSM-5. These include (on a gradient of psychopathology from least to most severe): schizotypal personality disorder, delusional disorder, brief psychotic disorder, substance-induced psychotic disorder, psychotic disorder associated with another medical condition, catatonic disorder associated with another medical condition, schizophreniform disorder, schizoaffective disorder, and schizophrenia. 1. Schizotypal personality disorder 2. Delusional disorder 3. Brief psychotic disorder 4. Substance-induced psychotic disorder 5. Psychotic disorder associated with another medical condition 6. Catatonic disorder associated with another medical condition 7. Schizophreniform disorder 8. Schizoaffective disorder 9. Schizophrenia

question

. ___________________________ disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania).

answer

ANS: Schizoaffective Rationale: Schizoaffective disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania). The decisive factor in the diagnosis of schizoaffective disorder is the presence of hallucinations and/or delusions that occur for at least 2 weeks in the absence of a major mood episode.

question

. ___________________________ are false sensory perceptions not associated with real external stimuli and may involve any of the five senses.

answer

ANS: Hallucinations Rationale: Hallucinations are false sensory perceptions not associated with real external stimuli and may involve any of the five senses. Types of hallucinations include auditory, visual, tactile, gustatory, and olfactory.

question

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), spends 1 hour packing and unpacking, folding and refolding personal belongings. What is the most likely reason for this behavior? a) It relieves anxiety. b) It fosters organizational skills. c) It delays meeting unfamiliar people in the dayroom d) It makes the client feel good.

answer

a) It relieves anxiety

question

For the last year, a college student continually and unrealistically worries about academic performance and love life performance. The student is irritable and suffers from severe insomnia. This behavior is associated with which diagnosis? a) Agoraphobia b) Generalized anxiety disorder (GAD) c) Social phobia disorder d) Obsessive-compulsive disorder (OCD)

answer

b) Generalized anxiety disorder (GAD)

question

When caring for a client who is experiencing a panic attack, which of the following nursing actions should be implemented? a) Leave the client alone to maintain privacy. b) Instruct the client regarding unit rules and regulations. c) Sit with the client in the day room to provide comfort. d) Communicate with simple words and brief messages.

answer

d) Communicate with simple words and brief messages.

question

What should the nurse plan to teach a client who is taking alprazolam (Xanax) three times a day? a) That there is a potential for dependence and tolerance. b) The importance of discontinuing Xanax immediately if addiction is suspected. c) That increased caffeine consumption can enhance the effectiveness of Xanax d) That Xanax is not habit forming.

answer

a) That there is a potential for dependence and tolerance.

question

Two months ago, Ms. T was sexually assaulted while jogging in an isolated park. She is hospitalized for suicidal ideation at this time. She awakens in the middle of the night screaming about having nightmares of the incident. Which of the following is the most appropriate initial nursing intervention? a) Call the doctor to report the incident b) Stay with Ms. T until the anxiety has subsided c) Administer prn alprazolam/Xanax d) Allow her some privacy to work through the emotions

answer

b) Stay with Ms. T until the anxiety has subsided

question

Which of the following medications is considered to be a first-line medication of choice in the treatment of PTSD? a) alprazolam/Xanax b) Propranolol c) carbamazepine/Tegretol d) paroxetine/Paxil

answer

d) paroxetine/Paxil

question

Shows no remorse for exploitation and manipulation of others.

answer

Antisocial Personality Disorder

question

Accepts a job he does not want to do, then does a poor job and delays past the deadline. Is negative and hostile toward others.

answer

Personality Disorder Trait Specified

question

Believes she is entitled to special privileges others do not deserve.

answer

Narcissistic Personality Disorder

question

Suspicious of all others with whom he comes in contact.

answer

Schizotypal Personality Disorder

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Swallows a bottle of pills after therapist leaves on vacation.

answer

Borderline Personality Disorder

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Believes he has a "sixth sense" and knows what others are thinking.

answer

Schizotypal Personality Disorder

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Refuses to enter into a relationship because of fear of rejection.

answer

Avoidant Personality Type

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Believes everyone must follow the rules and that the rules can be "bent" for no one—ever.

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OCD

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Requires a great deal of praise and becomes angry at the slightest criticism from others.

answer

Borderline Personality Disorder

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Has a devotion to productivity to the exclusion of personal pleasure.

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OCD

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Chronic feelings of depression are common.

answer

Borderline Personality Disorder

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Under stress, he often decompensates and demonstrates psychotic behaviors.

answer

Borderline Personality Disorder

question

A young man is brought into the emergency department by the police. He does not know who he is or anything at all about his life.

answer

Generalized Amnesia

question

A young man is brought into the emergency department by the police. He gives his identity and home address (which is several hundred miles away) to the admissions clerk. He tells the nurse he is very frightened, because he doesn't know when or how he came to be in this place.

answer

Dissociative Amnesia with Dissociative Fugue

question

Sandra is a clerk in an all-night convenience store. Three nights ago, the store was robbed at gunpoint, and Sandra was locked in a storage compartment for several hours until the manager was contacted by passersby who reported the robbery. She has been unable to recall the incident until just today, when details began to emerge. She is now able to report the entire event to the authorities.

answer

Localized Amnesia

question

Sam is a salesman for a leading manufacturing company. His job requires that he make presentations for large corporations that are considering Sam's company product. Sam is up for promotion and realizes that the outcomes of these presentations will weigh heavily on whether or not he gets the promotion. Lately, he has been worried that he is going insane. Each time he is about to make a presentation, his thinking becomes "foggy," his body feels lifeless, and he describes the feeling as being somewhat "anesthetized." These episodes sometimes last for hours and are beginning to interfere with his performance.

answer

Depersonaliation-Derealization Disorder

question

Melody's husband complained of severe chest pain. Melody called the ambulance and accompanied her husband to the hospital. He died of a massive myocardial infarction in the emergency department. With the help of family and friends, Melody made arrangements for the memorial service and the burial. Now that it is all over, Melody is able to remember only certain aspects about what has occurred since her husband first experienced the severe pain. She remembers the doctor telling her that her husband was dead, but she cannot remember attending the funeral service.

answer

Selective Amnesia

question

Margaret explains to the nurse that during the last year, she has had periods of time for which she cannot account. She has been attending college, and she finds pages of notes in her notebook that she cannot recall writing. Her roommate recently recounted an incident that took place when they were supposedly out together, for which Margaret has no recall. Recently, she was hospitalized when her roommate found her unconscious in their room with an empty bottle of sleeping pills beside her. She tells the nurse she has no memory of taking the pills.

answer

Dissociative Identity Disorder

question

An angry client on an inpatient unit approaches a nurse stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should only be addressed during group therapy.

answer

ANS: C The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

question

A client on an inpatient unit angrily states to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? A. "I'll talk to Peter and present your concerns." B. "Why are you overreacting to this issue?" C. "You should bring this to the attention of your treatment team." D. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

answer

ANS: D The most appropriate nursing response involves restating the client's feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

question

A newly admitted client asks, "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing reply? A. "Group therapy provides the opportunity to learn and practice new coping skills." B. "Group therapy is mandatory. All clients must attend." C. "Group therapy is optional. You can go if you find the topic helpful and interesting." D. "Group therapy is an economical way of providing therapy to many clients concurrently."

answer

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention.

question

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities

answer

ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups.

question

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients' bedside at the appropriate times.

answer

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

question

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management

answer

ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client's learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance.

question

What is the best rationale for including the client's family in therapy within the inpatient milieu? A. To structure a program of social and work-related activities B. To facilitate discharge from the hospital C. To provide a concrete demonstration of caring D. To encourage the family to model positive behaviors

answer

ANS: B The nurse should include the client's family in therapy within the inpatient milieu to facilitate discharge from the hospital. Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

question

How does a democratic form of self-government in the milieu contribute to client therapy? A. By setting punishments for clients who violate the community rules B. By dealing with inappropriate behaviors as they occur C. By setting community expectations wherein all clients are treated on an equal basis D. By interacting with professional staff members to learn about therapeutic interventions

answer

ANS: C A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis. Clients participate in the decision-making and problem-solving aspects that affect treatment setting. The norms, rules, and behavioral limits are established by the staff and clients. All individuals have input.

question

A client has undergone psychological testing. With which member of the interdisciplinary team should a nurse collaborate to review these results? A. The psychiatrist B. The psychiatric social worker C. The clinical psychologist D. The clinical nurse specialist

answer

ANS: C The nurse should consult with the clinical psychologist to review psychological testing results for the client. Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

question

In the role of milieu manager, which activity should the nurse prioritize? A. Setting the schedule for the daily unit activities B. Evaluating clients for medication effectiveness C. Conducting therapeutic group sessions D. Searching newly admitted clients for hazardous objects

answer

ANS: D The milieu manager should search newly admitted clients for hazardous objects. Safety of the client and others is the priority. Nurses are responsible for ensuring that the client's safety and physiological needs are met within the milieu.

question

A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? (Select all that apply.) A. Respiratory therapist and psychiatrist B. Occupational therapist and psychologist C. Recreational therapist and art therapist D. Social worker and hospital volunteer E. Mental health technician and chaplain

answer

ANS: B, C, E The interdisciplinary treatment team in a psychiatric inpatient setting consists of a psychologist, occupational therapist, recreational therapist, art therapist, mental health technician, and chaplain. In addition, a psychiatrist, psychiatric nurse, psychiatric social worker, music therapist, psychodramatist, and dietician participate in the interdisciplinary treatment team.

question

Which of the following are accurate descriptors of a therapeutic community? (Select all that apply.) A. The unit schedule includes unlimited free time for personal reflection. B. Unit responsibilities are assigned according to client capabilities. C. A flexible schedule is determined by client needs. D. The individual is the sole focus of therapy. E. A democratic form of government exists.

answer

ANS: B, E In a therapeutic community, the unit responsibilities are assigned according to client capability and a democratic form of government exists. Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

question

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Assess for medication noncompliance B. Note escalating behaviors and intervene immediately C. Interpret attempts at communication D. Assess triggers for bizarre, inappropriate behaviors

answer

ANS: B The nurse should note escalating behaviors and intervene immediately to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe.

question

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

answer

ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

question

A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

answer

ANS: A The nurse should explain that a chemical imbalance of the brain leads to altered thought processes. Hallucinations, or false sensory perceptions, may occur in all five senses. The client who hears voices is experiencing an auditory hallucination.

question

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

answer

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

question

A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference

answer

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

question

A client diagnosed with schizophrenia tells a nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is an appropriate charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoid delusion." D. "The client is verbalizing a word salad."

answer

ANS: B The nurse should describe the client's statement as experiencing a neologism. A neologism is when a client invents a new word that is meaningless to others but may have symbolic meaning to the client. Word salad refers to a group of words that are put together randomly.

question

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

answer

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

question

A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. The devil is not talking to you. This is part of your illness." D. "The devil only talks to people who are receptive to his influence."

answer

ANS: C The most appropriate reply by the nurse is to reassure the client with an accepting attitude while not reinforcing the hallucination. Reminding the client that "the voices" are a part of his or her illness is a way to help the client accept that the hallucinations are not real.

question

A client diagnosed with psychosis NOS (not otherwise specified) tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury

answer

ANS: C The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices telling him to kill someone is at risk for responding and reacting to the command hallucination. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions.

question

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.

answer

ANS: D The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence.

question

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia? A. Establishing personal contact with family members. B. Being reliable, honest, and consistent during interactions. C. Sharing limited personal information. D. Sitting close to the client to establish rapport.

answer

ANS: B The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior.

question

A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication B. Persecutory delusions; orient the client to reality C. Command hallucinations; warn the psychiatrist D. Altered thought processes; call an emergency treatment team meeting

answer

ANS: C The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. A client who is demonstrating a risk for violence could potentially become physically, emotionally, and/or sexually harmful to others or to self.

question

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

answer

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.

question

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

answer

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

question

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

answer

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

question

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

answer

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

question

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

answer

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

question

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

answer

ANS: A The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

question

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse immediately report to the client's attending psychiatrist? A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104F (40C) D. Excessive salivation

answer

ANS: C When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104F (40C). A temperature this high can be a symptom of the rare but life-threatening neuroleptic malignant syndrome.

question

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Watch your diet and try to engage in some regular physical activity." C. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."

answer

ANS: C The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic medications and beta blockers cause a decrease in blood pressure. When given in combination, this side effect places the client at risk for developing orthostatic hypotension.

question

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

answer

ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

question

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

answer

ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considering as a treatment option. Clozapine can have a serious side effect of agranulocytosis in which a potentially fatal drop in white blood cells can occur.

question

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

answer

ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

question

A college student has quit attending classes, isolates self due to hearing voices, and yells accusations at fellow students. Based on this information, which nursing diagnosis should the nurse prioritize? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood

answer

ANS: B The nursing diagnosis that must be prioritized in this situation should be risk for other-directed violence R/T yelling accusations. Hearing voices and yelling accusations indicates a potential for violence, and this potential safety issue should be prioritized.

question

A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking? A. Present evidence that supports the reality of the situation B. Focus on feelings suggested by the delusion C. Address the delusion with logical explanations D. Explore reasons why the client has the delusion

answer

ANS: B The nurse should focus on the client's feelings rather than attempt to change the client's delusional thinking by the use of evidence or logical explanations. Delusional thinking is usually fixed, and clients will continue to have the belief in spite of obvious proof that the belief is false or irrational.

question

A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.

answer

ANS: C It is unrealistic to expect the client to completely stop hearing voices. Even when compliant with antipsychotic medications, clients may still hear voices. It would be realistic to expect the client to associate stressful events with an increase in auditory hallucinations. By this recognition the client can anticipate symptoms and initiate appropriate coping skills.

question

A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms? A. The client has developed tolerance to the antipsychotic medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.

answer

ANS: C Altered thinking can affect a client's insight into the necessity for taking antipsychotic medications consistently. When symptoms are no longer bothersome, clients may stop taking medications that cause disturbing side effects. Clients may miss the connection between taking the medications and an improved symptom profile.

question

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? (Select all that apply.) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

answer

ANS: A, B, D, E The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

question

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

answer

ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

question

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions

answer

ANS: A, B, C The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.

question

A client is diagnosed with dysthymic disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

answer

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymic disorder. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological.

question

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

answer

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

question

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

answer

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.

question

A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

answer

ANS: A According to the DSM-IV-TR, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level which results from a low thyroid function or hypothyroidism. In hypothyroidism, metabolic processes are slowed leading to depressive symptoms.

question

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? A. According to psychoanalytic theory, depression is a result of anger turned inward. B. According to object-loss theory, depression is a result of abandonment. C. According to learning theory, depression is a result of repeated failures. D. According to cognitive theory, depression is a result of negative perceptions.

answer

ANS: C The nurse should assess that this client's depressive symptoms may have resulted from repeated failures. This assessment was based on the principles of learning theory. Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

question

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

answer

ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.

question

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

answer

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

question

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out senile dementia D. To rule out a personality disorder

answer

ANS: C A mini-mental status exam should be performed to rule out senile dementia. The elderly are often misdiagnosed with senile dementia when depression is their actual diagnosis. Memory loss, confused thinking, or apathy symptomatic of dementia actually may be the result of depression.

question

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

answer

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

question

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

answer

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

question

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

answer

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

question

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

answer

ANS: B Buspar takes at least 2 to 3 weeks to be effective in controlling symptoms of depression. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

question

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

answer

ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

question

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

answer

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

question

Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.

answer

ANS: C Zoloft is a selective serotonin reuptake inhibitor (SSRI) that has a relatively benign side effect profile as compared with other antidepressants.

question

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular blood work B. The client's mood and affect score, using the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

answer

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

question

A client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

answer

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. The diagnosis of SAD is not associated with a traumatic event.

question

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

answer

ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

question

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.

answer

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe based on assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

question

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

answer

ANS: C When a nurse assesses and attempts to modify negative thought patterns related to depressive symptoms, the nurse is using a cognitive theory framework.

question

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."

answer

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. Depressive symptoms are often described as anger turned inward.

question

A 75-year-old client diagnosed with a long history of depression is currently on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

answer

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

question

A client is admitted with a diagnosis of depression NOS (not otherwise specified). Which client statement would describe a somatic symptom that can occur with this diagnosis? A. "I am extremely sad, but I don't know why." B. "Sometimes I just don't want to eat because I ache all over." C. "I feel like I can't ever make the right decision." D. "I can't seem to leave the house without someone with me."

answer

ANS: B When a client diagnosed with depression expresses physical complaints, the client is experiencing somatic symptoms. Somatic symptoms occur with depression because of a general slowdown of the entire body reflected in sluggish digestion, constipation, impotence, anorexia, difficulty falling asleep, and a wide variety of other symptoms.

question

A client diagnosed with major depressive disorder was raised in an excessively religiously based household. Which nursing intervention would be most appropriate to address this client's underlying problem? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

answer

ANS: A A client raised in an excessively religiously based household maybe at risk for experiencing guilt to the point of accepting liability in situations for which one is not responsible. The client may view himself or herself as evil and deserving of punishment leading to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

question

A nurse is caring for four clients taking various medications including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

answer

ANS: D Hypertensive crisis occurs in clients receiving monoamine oxidase inhibitor (MAOI) who consume foods or drugs high in tyramine content.

question

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Expressions of poor self-esteem

answer

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Depressed clients do not care enough about themselves to participate in grooming and hygiene.

question

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "I'm glad you shared this. There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

answer

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

question

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) A. Sad mood on most days B. Mood rating of 2/10 for the past 6 months C. Labile mood D. Sad mood for the past 3 years after spouse's death E. Pressured speech when communicating

answer

ANS: A, D The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than 2 years. The essential feature of dysthymia is a chronically depressed mood which can have an early or late onset.

question

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

answer

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

question

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

answer

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs due to the risk of drug interactions.

question

A client rates anxiety at 8 out of 10 on a scale of 1 to 10, is restless, and has narrowed perceptions. Which of the following medications would appropriately be prescribed to address these symptoms? Select all that apply. 1. Chlordiazepoxide (Librium). 2. Clonazepam (Klonopin). 3. Lithium carbonate (lithium). 4. Clozapine (Clozaril). 5. Oxazepam (Serax).

answer

An anxiety rating of 8 out of 10, restlessness, and narrowed perceptions all are symptoms of increased levels of anxiety. 1. Chlordiazepoxide (Librium) is a benzodiazepine. Benzodiazepines are classified as antianxiety medications and would be appropriately prescribed to address signs and symptoms of anxiety. 2. Clonazepam (Klonopin) is a benzodiazepine. Benzodiazepines are classified as antianxiety medications and would be appropriately prescribed to address signs and symptoms of anxiety. 5. Oxazepam (Serax) is a benzodiazepine. Benzodiazepines are classified as antianxiety medications and would be appropriately prescribed to address signs and symptoms of anxiety. TEST-TAKING HINT: The test taker first must recognize the signs and symptoms presented in the question as an indication of increased levels of anxiety. Next, the test taker must recognize the medications that address these symptoms. Also, it is common to confuse lithium carbonate (lithium) and Librium and clozapine and clonazepam. To answer this question correctly, the test taker needs to distinguish between medications that are similar in spelling.

question

A client diagnosed with generalized anxiety disorder is placed on clonazepam (Klonopin) and buspirone (BuSpar). Which client statement indicates teaching has been effective? 1. The client verbalizes that the clonazepam (Klonopin) is to be used for long-term therapy in conjunction with buspirone (BuSpar). 2. The client verbalizes that buspirone (BuSpar) can cause sedation and should be taken at night. 3. The client verbalizes that clonazepam (Klonopin) is to be used short-term until the buspirone (BuSpar) takes full effect. 4. The client verbalizes that tolerance can result with long-term use of buspirone (BuSpar).

answer

3. Clonazepam would be used for shortterm treatment while waiting for the buspirone to take full effect, which can take 4 to 6 weeks. TEST-TAKING HINT: To answer this question correctly, the test taker must note appropriate teaching needs for clients prescribed different classifications of antianxiety medications.

question

In which situation would benzodiazepines be prescribed appropriately? 1. Long-term treatment of posttraumatic stress disorder, convulsive disorder, and alcohol withdrawal. 2. Short-term treatment of generalized anxiety disorder, alcohol withdrawal, and preoperative sedation. 3. Short-term treatment of obsessive-compulsive disorder, skeletal muscle spasms, and essential hypertension. 4. Long-term treatment of panic disorder, alcohol dependence, and bipolar affective disorder: manic episode.

answer

2. Benzodiazepines are prescribed for shortterm treatment of generalized anxiety disorder and alcohol withdrawal, and can be prescribed during preoperative sedation. TEST-TAKING HINT: The test taker needs to note the words "long-term" and "short-term" in the answers. Benzodiazepines are prescribed in the short-term because of their addictive properties. The test taker must understand that when taking a test, if one part of the answer is incorrect, the whole answer is incorrect, as in answer choice "3."

question

A client recently diagnosed with generalized anxiety disorder is prescribed clonazepam (Klonopin), buspirone (BuSpar), and citalopram (Celexa). Which assessment related to the concurrent use of these medications is most important? 1. Monitor for signs and symptoms of worsening depression and suicidal ideation. 2. Monitor for changes in mental status, diaphoresis, tachycardia, and tremor. 3. Monitor for hyperpyresis, dystonia, and muscle rigidity. 4. Monitor for spasms of face, legs, and neck and for bizarre facial movements.

answer

2. It is important for the nurse to monitor for serotonin syndrome, which occurs when a client takes multiple medications that affect serotonin levels. Symptoms include change in mental status, restlessness, myoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, and tremor. TEST-TAKING HINT: To answer this question correctly, the test taker must be familiar with the signs and symptoms of serotonin syndrome and which psychotropic medications affect serotonin, potentially leading to this syndrome.

question

Which of the following symptoms are seen when a client abruptly stops taking diazepam (Valium)? Select all that apply. 1. Insomnia. 2. Tremor. 3. Delirium. 4. Dry mouth. 5. Lethargy.

answer

Diazepam (Valium) is a benzodiazepine. Benzodiazepines are physiologically and psychologically addictive. If a benzodiazepine is stopped abruptly, a rebound stimulation of the central nervous system occurs, and the client may experience insomnia, increased anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions, and delirium. 1. Insomnia is correct. 2. Tremor is correct. 3. Delirium is correct. 4. Dry mouth is a side effect of taking benzodiazepines and is not related to stopping the medication abruptly. 5. Lethargy is a side effect of taking benzodiazepines and is not related to stopping the medication abruptly. TEST-TAKING HINT: The test taker must distinguish between benzodiazepine side effectsand symptoms of withdrawal to answer this question correctly.

question

From a cognitive theory perspective, which is a possible cause of panic disorder? 1. Inability of the ego to intervene when conflict occurs. 2. Abnormal elevations of blood lactate and increased lactate sensitivity. 3. Increased involvement of the neurochemical norepinephrine. 4. Distorted thinking patterns that precede maladaptive behaviors.

answer

4. Distorted thinking patterns that precede maladaptive behaviors relate to the cognitive theory perspective of panic disorder development. TEST-TAKING HINT: The test taker should note important words in the question, such as "cognitive." Although all of the answers are potential causes of panic disorder development, the only answer that is from a cognitive perspective is "4."

question

An overuse or ineffective use of ego defense mechanisms, which results in a maladaptive response to anxiety, is an example of the ___________________ theory of generalized anxiety disorder development.

answer

An overuse or ineffective use of ego defense mechanisms, which results in a maladaptiveresponse to anxiety, is an example of thepsychodynamic theory of generalized anxiety disorder development. TEST-TAKING HINT: To answer this question correctly, the test taker should review the various theories related to the development of generalized anxiety disorder.

question

A client diagnosed with posttraumatic stress disorder is close to discharge. Which client statement would indicate that teaching about the psychosocial cause of posttraumatic stress disorder was effective? 1. "I understand that the event I experienced, how I deal with it, and my support system all affect my disease process." 2. "I have learned to avoid stressful situations as a way to decrease emotional pain." 3. "So, natural opioid release during the trauma caused my body to become 'addicted.'" 4. "Because of the trauma, I have a negative perception of the world and feel hopeless."

answer

1. When the client verbalizes understanding of how the experienced event, individual traits, and available support systems affect his or her diagnosis, the client demonstrates a good understanding of the psychosocial cause of posttraumatic stress disorder (PTSD). To answer this question correctly, the test taker should review the different theories as they relate to the causes of different anxiety disorders, including PTSD. Only "1" describes a psychosocial etiology of PTSD.

question

Counselors have been sent to a location that has experienced a natural disaster to assist the population to deal with the devastation. This is an example of __________________ prevention.

answer

4. Sending counselors to a natural disaster site to assist individuals to deal with the devastation is an example of primary prevention. Primary prevention reduces the incidence of mental disorders, such as posttraumatic stress disorder, within the population by helping individuals to cope more effectively with stress early in the grieving process. Primary prevention is extremely important for individuals who experience any traumatic event, such as a rape, war, hurricane, tornado, or school shooting. TEST-TAKING HINT: To answer this question correctly, it is necessary to understand the differences between primary, secondary, and tertiary prevention.

question

Which of the following statements explains the etiology of obsessive-compulsive disorder (OCD) from a biological theory perspective? 1. Individuals diagnosed with OCD have weak and underdeveloped egos. 2. Obsessive and compulsive behaviors are a conditioned response to a traumatic event. 3. Regression to the pre-Oedipal anal sadistic phase produces the clinical symptoms of OCD. 4. Abnormalities in various regions of the brain have been implicated in the cause of OCD.

answer

4. The belief that abnormalities in various regions of the brain cause OCD is an explanation of OCD etiology from a biological theory perspective. TEST-TAKING HINT: To answer this question correctly, the test taker must understand the different theories of OCD etiology. This question calls for a biological theory perspective, making "4" the only correct choice.

question

After being diagnosed with pyrophobia, the client states, "I believe this started at the age of 7 when I was trapped in a house fire." When examining theories of phobia etiology, this situation would be reflective of ____________ theory.

answer

When examining theories of phobia etiology, this situation would be reflective of learning theory. Some learning theorists believe that fears are conditioned responses, and they are learned by imposing rewards for certain behaviors. In the instance of phobias, when the individual avoids the phobic object, he or she escapes fear, which is a powerful reward. This client has learned that avoiding the stimulus of fire eliminates fear. TEST-TAKING HINT: To answer this question correctly, the test taker needs to review the different theories of the causation of specific phobias.

question

A client diagnosed with social phobia has an outcome that states, "Client will voluntarily participate in group activities with peers by day 3." Which would be an appropriate intrapersonal intervention by the nurse to assist the client to achieve this outcome? 1. Offer PRN lorazepam (Ativan) 1 hour before group begins. 2. Attend group with client to assist in decreasing anxiety. 3. Encourage discussion about fears related to socialization. 4. Role-play scenarios that may occur in group to decrease anxiety.

answer

3. Encouraging discussion about fears is an intrapersonal intervention. TEST-TAKING HINT: It is important to understand that interventions are based on theories of causation. In this question, the test taker needs to know that intrapersonal theory relates to feelings or developmental issues. Only "3" deals with client feelings.

question

Using psychodynamic theory, which intervention would be appropriate for a client diagnosed with panic disorder? 1. Encourage the client to evaluate the power of distorted thinking. 2. Ask the client to include his or her family in scheduled therapy sessions. 3. Discuss the overuse of ego defense mechanisms and their impact on anxiety. 4. Teach the client about the effect of blood lactate level as it relates to the client's panic attacks.

answer

3. The nurse discussing the overuse of ego defense mechanisms illustrates a psychodynamic approach to address the client's behaviors related to panic disorder. TEST-TAKING HINT: When answering this question, the test taker must be able to differentiate among various theoretical perspectives and their related interventions.

question

Which nursing diagnosis reflects the intrapersonal theory of the etiology of obsessivecompulsive disorder? 1. Ineffective coping R /T punitive superego. 2. Ineffective coping R /T active avoidance. 3. Ineffective coping R /T alteration in serotonin. 4. Ineffective coping R /T classic conditioning.

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1. Ineffective coping R /T punitive superego reflects an intrapersonal theory of the etiology of obsessive-compulsive disorder (OCD). The punitive superego is a concept contained in Freud's psychosocial theory of personality development. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand the different theories of the etiology of OCD. The keyword "intrapersonal" should make the test taker look for a concept inherent in this theory, such as "punitive superego."

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The nurse is using an intrapersonal approach to assist a client in dealing with survivor's guilt. Which intervention would be appropriate? 1. Encourage the client to attend a survivor's group. 2. Encourage expression of feelings during one-to-one interactions with the nurse. 3. Ask the client to challenge the irrational beliefs associated with the event. 4. Administer regularly scheduled paroxetine (Paxil) to deal with depressive symptoms.

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2. Encouraging expressions of feelings during one-to-one interactions with the nurse is an intrapersonal approach to interventions that treat survivor's guilt associated with PTSD. TEST-TAKING HINT: To answer this question correctly, the test taker needs to differentiate various theoretical approaches and which interventions reflect these theories.

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A client diagnosed with posttraumatic stress disorder states to the nurse, "All those wonderful people died, and yet I was allowed to live." Which is the client experiencing? 1. Denial. 2. Social isolation. 3. Anger. 4. Survivor's guilt.

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4. The client in the question is experiencing survivor's guilt. Survivor's guilt is a common situation that occurs when an individual experiences a traumatic event in which others died and the individual survived. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand common phenomena experienced by individuals diagnosed with posttraumatic stress disorder and relate this understanding to the client statement presented in the question.

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Clients diagnosed with obsessive-compulsive disorder commonly use which mechanism? 1. Suppression. 2. Repression. 3. Undoing. 4. Denial.

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3. Undoing is a defense mechanism commonly used by individuals diagnosed with OCD. Undoing is used symbolically to negate or cancel out an intolerable previous action or experience. An individual diagnosed with OCD experiencing intolerable anxiety would use the defense mechanism of undoing to undo this anxiety by substituting obsessions or compulsions or both. Other commonly used defense mechanisms are isolation, displacement, and reaction formation. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand the underlying reasons for the ritualistic behaviors used by individuals diagnosed with OCD.

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Which of the following would the nurse expect to assess in a client diagnosed with posttraumatic stress disorder? Select all that apply. 1. Dissociative events. 2. Intense fear and helplessness. 3. Excessive attachment and dependence toward others. 4. Full range of affect. 5. Avoidance of activities that are associated with the trauma.

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1. A client diagnosed with posttraumatic stress disorder (PTSD) may have dissociative events in which the client feels detached from the situation or feelings. 2. A client diagnosed with PTSD may have intense fear and feelings of helplessness. 5. A client diagnosed with PTSD avoids activities associated with the traumatic event. TEST-TAKING HINT: To answer this question correctly, the test taker must be aware of the different symptoms associated with the diagnosis of PTSD.

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When treating individuals with posttraumatic stress disorder, which variables are included in the recovery environment? 1. Degree of ego strength. 2. Availability of social supports. 3. Severity and duration of the stressor. 4. Amount of control over reoccurrence.

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2. Availability of social supports is part of environmental variables. Others include cohesiveness and protectiveness of family and friends, attitudes of society regarding the experience, and cultural and subcultural influences. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand the following three significant elements in the development of posttraumatic stress disorder: traumatic experience, individual variables, and environmental variables.

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A newly admitted client is diagnosed with posttraumatic stress disorder. Which behavioral symptom would the nurse expect to assess? 1. Recurrent, distressing flashbacks. 2. Intense fear, helplessness, and horror. 3. Diminished participation in significant activities. 4. Detachment or estrangement from others.

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3. Diminished participation in significant activities is a behavioral symptom of PTSD. TEST-TAKING HINT: To answer this question correctly, the test taker should take note of the keyword "behavioral," which determines the correct answer. All symptoms may be exhibited in PTSD, but only answer choice "3" is a behavioral symptom.

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Which of the following assessment data would support the disorder of acrophobia? 1. A client is fearful of basements because of encountering spiders. 2. A client refuses to go to Europe because of fear of flying. 3. A client is unable to commit to marriage after a 10-year engagement. 4. A client refuses to leave home during stormy weather.

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2. Acrophobia is the fear of heights. An individual experiencing acrophobia may be unable to fly because of this fear. TEST-TAKING HINT: To answer this question correctly, the test taker needs to review the definitions of specific commonly diagnosed phobias.

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In which situation would the nurse suspect a medical diagnosis of social phobia? 1. A client abuses marijuana daily and avoids social situations because of fear of humiliation. 2. An 8-year-old child isolates from adults because of fear of embarrassment, but has good peer relationships in school. 3. A client diagnosed with Parkinson's disease avoids social situations because of embarrassment regarding tremors and drooling. 4. A college student avoids taking classes that include an oral presentation because of fear of being scrutinized by others.

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4. A student who avoids classes because of the fear of being scrutinized by others meets the criteria for a diagnosis of social phobia. TEST-TAKING HINT: The test taker must understand the DSM-IV-TR diagnostic criteria for social phobia to answer this question correctly.

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A client experiencing a panic attack would display which physical symptom? 1. Fear of dying. 2. Sweating and palpitations. 3. Depersonalization. 4. Restlessness and pacing.

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2. Sweating and palpitations are physical symptoms of a panic attack. TEST-TAKING HINT: The test taker must note important words in the question, such as "physical symptoms." Although all the answers are actual symptoms a client experiences during a panic attack, only "2" is a physical symptom.

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A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessivecompulsive disorder. Which behavioral symptom would the nurse expect to assess? 1. The client uses excessive hand washing to relieve anxiety. 2. The client rates anxiety at 8/10. 3. The client uses breathing techniques to decrease anxiety. 4. The client exhibits diaphoresis and tachycardia.

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1. Using excessive hand washing to relieve anxiety is a behavioral symptom exhibited by clients diagnosed with obsessivecompulsive disorder (OCD). TEST-TAKING HINT: To answer this question correctly, the test taker must be able to differentiate various classes of symptoms exhibited by clients diagnosed with OCD. The keyword "behavioral" determines the correct answer to this question.

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A client with a history of generalized anxiety disorder enters the emergency department complaining of restlessness, irritability, and exhaustion. Vital signs are blood pressure 140/90 mm Hg, pulse 96, and respirations 20. Based on this assessed information, which assumption would be correct? 1. The client is exhibiting signs and symptoms of an exacerbation of generalized anxiety disorder. 2. The client's signs and symptoms are due to an underlying medical condition. 3. A physical examination is needed to determine the etiology of the client's problem. 4. The client's anxiolytic dosage needs to be increased.

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3. Physical problems should be ruled out before determining a psychological cause for this client's symptoms. TEST-TAKING HINT: The test taker needs to remember that although a client may have a history of a psychiatric illness, a complete, thorough evaluation must be done before assuming exhibited symptoms are related to the psychiatric diagnosis. Many medical conditions generate anxiety as a symptom.

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Anxiety is a symptom that can result from which of the following physiological conditions? Select all that apply. 1. Chronic obstructive pulmonary disease. 2. Hyperthyroidism. 3. Hypertension. 4. Diverticulosis. 5. Hypoglycemia.

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1. Chronic obstructive pulmonary disease causes shortness of breath. Air deprivation causes anxiety, sometimes to the point of panic. 2. Hyperthyroidism (Graves's disease) involves excess stimulation of the sympathetic nervous system and excessive levels of thyroxine. Anxiety is one of several symptoms brought on by these increases. 5. Marked irritability and anxiety are some of the many symptoms associated with hypoglycemia. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand that anxiety is manifested by physiological responses.

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Which assessment data would support a physician's diagnosis of an anxiety disorder in a client? 1. A client experiences severe levels of anxiety in one area of functioning. 2. A client experiences an increased level of anxiety in one area of functioning for a 6-month period. 3. A client experiences increased levels of anxiety that affect functioning in more than one area of life over a 6-month period. 4. A client experiences increased levels of anxiety that affect functioning in at least three areas of life.

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3. For a client to be diagnosed with an anxiety disorder, the client must experience symptoms that interfere in a minimum of two areas, such as social, occupational, or other important functioning. These symptoms must be experienced for durations of 6 months or longer. TEST-TAKING HINT: To answer this question correctly, the test taker must understand that specific symptoms must be exhibited and specific timeframes achieved for clients to be diagnosed with anxiety disorders.

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Which of the following symptom assessments would validate the diagnosis of generalized anxiety disorder? Select all that apply. 1. Excessive worry about items difficult to control. 2. Muscle tension. 3. Hypersomnia. 4. Excessive amounts of energy. 5. Feeling "keyed up" or "on edge."

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1. A client diagnosed with generalized anxiety disorder (GAD) would experience excessive worry about items difficult to control. 2. A client diagnosed with GAD would experience muscle tension. 5. A client diagnosed with GAD would experience an increased startle reflex and tension, causing feelings of being "keyed up" or being "on edge." TEST-TAKING HINT: To answer this question correctly, the test taker would need to recognize the signs and symptoms of GAD.

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A client diagnosed with obsessive-compulsive disorder is newly admitted to an inpatient psychiatric unit. Which cognitive symptom would the nurse expect to assess? 1. Compulsive behaviors that occupy more than 4 hours per day. 2. Excessive worrying about germs and illness. 3. Comorbid abuse of alcohol to decrease anxiety. 4. Excessive sweating and an increase in blood pressure and pulse.

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2. Excessive worrying about germs and illness is a cognitive symptom experienced by clients diagnosed with OCD. TEST-TAKING HINT: To answer this question correctly, the test taker must note the keyword "cognitive." Only "2" is a cognitive symptom.

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A newly admitted client diagnosed with posttraumatic stress disorder is exhibiting recurrent flashbacks, nightmares, sleep deprivation, and isolation from others. Which nursing diagnosis takes priority? 1. Posttrauma syndrome R /T a distressing event AEB flashbacks and nightmares. 2. Social isolation R /T anxiety AEB isolating because of fear of flashbacks. 3. Ineffective coping R /T flashbacks AEB alcohol abuse and dependence. 4. Risk for injury R /T exhaustion because of sustained levels of anxiety.

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4. Risk for injury is the priority nursing diagnosis for this client. In the question, the client is exhibiting recurrent flashbacks, nightmares, and sleep deprivation that can cause exhaustion and lead to injury. It is important for the nurse to prioritize the nursing diagnosis that addresses safety. TEST-TAKING HINT: When the question asks for a priority, it is important for the test taker to understand that all answer choices may be appropriate statements. Client safety always should be prioritized.

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A client leaving home for the first time in a year arrives on the psychiatric in-patient unit wearing a surgical mask and white gloves and crying, "The germs in here are going to kill me." Which nursing diagnosis addresses this client's problem? 1. Social isolation R /T fear of germs AEB continually refusing to leave the home. 2. Fear of germs R /T obsessive-compulsive disorder, resulting in dysfunctional isolation. 3. Ineffective coping AEB dysfunctional isolation R /T unrealistic fear of germs. 4. Anxiety R /T the inability to leave home, resulting in dysfunctional fear of germs.

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1. According to the North American Nursing Diagnosis Association (NANDA), the nursing diagnosis format must contain three essential components: (1) identification of the health problem, (2) presentation of the etiology (or cause) of the problem, and (3) description of a cluster of signs and symptoms known as "defining characteristics." The correct answer, "1," contains all three components in the correct order: health problem/NANDA stem (social isolation); etiology/cause, or R /T (fear of germs); and signs and symptoms, or AEB (refusing to leave home for the past year). Because this client has been unable to leave home for a year as a result of fear of germs, the client's behaviors meet the defining characteristics of social isolation. TEST-TAKING HINT: To answer this question correctly, the test taker needs to know the components of a correctly stated nursing diagnosis and the order in which these components are written.

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A client seen in an out-patient clinic for ongoing management of panic attacks states, "I have to make myself come to these appointments. It is hard because I don't know when an attack will occur." Which nursing diagnosis takes priority? 1. Ineffective breathing patterns R /T hyperventilation. 2. Impaired spontaneous ventilation R /T panic levels of anxiety. 3. Social isolation R /T fear of spontaneous panic attacks. 4. Knowledge deficit R /T triggers for panic attacks.

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3. Social isolation is seen frequently with individuals diagnosed with panic attacks. The client in the question expresses anticipatory fear of unexpected attacks, which affects the client's ability to interact with others. TEST-TAKING HINT: To answer this question correctly, the test taker must link the behaviors presented in the question with the nursing diagnosis that is reflective of these behaviors. The test taker must remember the importance of time-wise interventions. Nursing interventions differ according to the degree of anxiety the client is experiencing. If the client were currently experiencing a panic attack, other interventions would be appropriate.

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A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessivecompulsive disorder. Which correctly stated nursing diagnosis takes priority? 1. Anxiety R /T obsessive thoughts AEB ritualistic behaviors. 2. Powerlessness R /T ritualistic behaviors AEB statements of lack of control. 3. Fear R /T a traumatic event AEB stimulus avoidance. 4. Social isolation R /T increased levels of anxiety AEB not attending groups.

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1. Anxiety is the underlying cause of the diagnosis of obsessive compulsive disorder (OCD), therefore, anxiety R/T obsessive thoughts is the priority nursing diagnosis for the client newly admitted for the treatment of this disorder. TEST-TAKING HINT: When the question is asking for a priority, the test taker should consider which client problem would need to be addressed before any other problem can be explored. When anxiety is decreased, social isolation should improve, and feelings about powerlessness can be expressed.

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During an assessment, a client diagnosed with generalized anxiety disorder rates anxiety as 9/10 and states, "I have thought about suicide because nothing ever seems to work out for me." Based on this information, which nursing diagnosis takes priority? 1. Hopelessness R /T anxiety AEB client's stating, "Nothing ever seems to work out." 2. Ineffective coping R /T rating anxiety as 9/10 AEB thoughts of suicide. 3. Anxiety R /T thoughts about work AEB rates anxiety 9/10. 4. Risk for suicide R /T expressing thoughts of suicide.

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4. Because the client is expressing suicidal ideations, the nursing diagnosis of risk for suicide takes priority at this time. Client safety is prioritized over all other client problems. TEST-TAKING HINT: When looking for a priority nursing diagnosis, the test taker always must prioritize client safety. Even if other problems exist, client safety must be ensured.

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A hospitalized client diagnosed with posttraumatic stress disorder has a nursing diagnosis of ineffective coping R /T history of rape AEB abusing alcohol. Which is the expected short-term outcome for this client problem? 1. The client will recognize triggers that precipitate alcohol abuse by day 2. 2. The client will attend follow-up weekly therapy sessions after discharge. 3. The client will refrain from self-blame regarding the rape by day 2. 4. The client will be free from injury to self throughout the shift.

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1. It is a realistic expectation for a client who copes with previous trauma by abusing alcohol to recognize the triggers that precipitate this behavior. This outcome should be developed mutually early in treatment. TEST-TAKING HINT: It is important to relate outcomes to the stated nursing diagnosis. In this question, the test taker should choose an answer that relates to the nursing diagnosis of ineffective coping. Answer "4" can be eliminated immediately because it does not assist the client in coping more effectively. Also, the test taker must note important words, such as "short-term." Answer "2" can be eliminated immediately because it is a long-term outcome.

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Which client would the charge nurse assign to an agency nurse who is new to a psychiatric setting? 1. A client diagnosed with posttraumatic stress disorder currently experiencing flashbacks. 2. A newly admitted client diagnosed with generalized anxiety disorder beginning benzodiazepines for the first time. 3. A client admitted 4 days ago with the diagnosis of algophobia. 4. A newly admitted client with obsessive-compulsive disorder.

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3. A client admitted 4 days ago with a diagnosis of algophobia, fear of pain, would be an appropriate assignment for the agency nurse. Of the clients presented, this client would pose the least challenge to a nurse unfamiliar with psychiatric clients. TEST-TAKING HINT: To answer this question correctly, the test taker needs to recognize the complexity of psychiatric diagnoses and understand the ramifications of potentially inappropriate nursing interventions by inexperienced staff members.

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A newly admitted client diagnosed with social phobia has a nursing diagnosis of social isolation R/T fear of ridicule. Which outcome is appropriate for this client? 1. The client will participate in two group activities by day 4. 2. The client will use relaxation techniques to decrease anxiety. 3. The client will verbalize one positive attribute about self by discharge. 4. The client will request buspirone (BuSpar) PRN to attend group by day 2.

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1. Expecting the client to participate in a set number of group activities by day 4 directly relates to the stated nursing diagnosis of social isolation and is a measurable outcome that includes a timeframe. TEST-TAKING HINT: To express an appropriate outcome, the statement must be related to the stated problem, be measurable and attainable, and have a timeframe. The test taker can eliminate "2" immediately because there is no timeframe, and then "3" because it does not relate to the stated problem.

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When a client experiences a panic attack, which outcome takes priority? 1. The client will remain safe throughout the duration of the panic attack. 2. The client will verbalize an anxiety level less than 2/10. 3. The client will use learned coping mechanisms to decrease anxiety. 4. The client will verbalize the positive effects of exercise by day 2.

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1. Remaining safe throughout the duration of the panic attack is the priority outcome for the client. TEST-TAKING HINT: All outcomes must be appropriate for the situation described in the question. In the question, the client is experiencing a panic attack; having the client verbalize the positive effects of exercise would be inappropriate. All outcomes must be client-centered, specific, realistic, positive, and measurable, and contain a timeframe.

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The nurse has received evening report. Which client would the nurse need to assess first? 1. A newly admitted client with a history of panic attacks. 2. A client who slept 2 to 3 hours last night because of flashbacks. 3. A client pacing the halls and stating that his anxiety is an 8/10. 4. A client diagnosed with generalized anxiety disorder awaiting discharge.

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3. A client pacing the halls and experiencing an increase in anxiety commands immediate assessment. If the nurse does not take action on this assessment, there is a potential for client injury to self or others. TEST-TAKING HINT: When the nurse is prioritizing client assessments, it is important to note which client might be a safety risk. When asked to prioritize, the test taker must review all the situations presented before deciding which one to address first.

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A client was admitted to an in-patient psychiatric unit 4 days ago for the treatment of obsessive-compulsive disorder. Which outcome takes priority for this client at this time? 1. The client will use a thought-stopping technique to eliminate obsessive/compulsive behaviors. 2. The client will stop obsessive and/or compulsive behaviors. 3. The client will seek assistance from the staff to decrease obsessive or compulsive behaviors. 4. The client will use one relaxation technique to decrease obsessive or compulsive behaviors.

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4. By day 4, it would be realistic to expect the client to use one relaxation technique to decrease obsessive or compulsive behaviors. This would be the current priority outcome. TEST-TAKING HINT: The test taker must recognize the importance of time-wise interventions when establishing outcomes. In the case of clients diagnosed with obsessive-compulsive disorder, expectations on admission vary greatly from outcomes developed closer to discharge.

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A client diagnosed with generalized anxiety disorder has a nursing diagnosis of panic anxiety R/T altered perceptions. Which of the following short-term outcomes is most appropriate for this client? 1. The client will be able to intervene before reaching panic levels of anxiety by discharge. 2. The client will verbalize decreased levels of anxiety by day 2. 3. The client will take control of life situations by using problem-solving methods effectively. 4. The client will voluntarily participate in group therapy activities by discharge.

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1. The client's being able to intervene before reaching panic levels of anxiety by discharge is measurable, relates to the stated nursing diagnosis, has a timeframe, and is an appropriate short-term outcome for this client. TEST-TAKING HINT: When evaluating outcomes, the test taker must make sure that the outcome is specific to the client's need, is realistic, is measurable, and contains a reasonable timeframe. If any of these components is missing, the outcome is incorrectly written and can be eliminated.

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A 10-year-old client diagnosed with nightmare disorder is admitted to an in-patient psychiatric unit. Which of the following interventions would be appropriate for this client's problem? Select all that apply. 1. Involving the family in therapy to decrease stress within the family. 2. Using phototherapy to assist the client to adapt to changes in sleep. 3. Administering medications such as tricyclic antidepressants or low-dose benzodiazepines or both. 4. Giving central nervous system stimulants, such as amphetamines. 5. Using relaxation therapy, such as meditation and deep breathing techniques, to assist the client in falling asleep.

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1. Family stress can occur as the result of repeated client nightmares. This stress within the family may exacerbate the client's problem and hamper any effective treatment. Involving the family in therapy to relieve obvious stress would be an appropriate intervention to assist in the treatment of clients diagnosed with a nightmare disorder. 3. Administering medications such as tricyclic antidepressants or low-dose benzodiazepines or both is an appropriate intervention for clients diagnosed with a parasomnia disorder, such as a nightmare disorder. 5. Relaxation therapy, such as meditation and deep breathing techniques, would be appropriate for clients diagnosed with a nightmare disorder to assist in falling back to sleep after the nightmare occurs. TEST-TAKING HINT: To answer this question correctly, the test taker must be able first to understand the manifestation of a nightmare disorder and then to choose the interventions that would address these manifestations effectively.

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A client on an in-patient psychiatric unit is experiencing a flashback. Which intervention takes priority? 1. Maintain and reassure the client of his or her safety and security. 2. Encourage the client to express feelings. 3. Decrease extraneous external stimuli. 4. Use a nonjudgmental and matter-of-fact approach.

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1. During a flashback, the client is experiencing severe-to-panic levels of anxiety; the priority nursing intervention is to maintain and reassure the client of his or her safety and security. The client's anxiety needs to decrease before other interventions are attempted. TEST-TAKING HINT: It is important to understand time-wise interventions when dealing with individuals experiencing anxiety. When the client experiences severe-to-panic levels of anxiety during flashbacks, the nurse needs to maintain safety and security until the client's level of anxiety has decreased.

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A client diagnosed with panic attacks is being admitted for the fifth time in 1 year because of hopelessness and helplessness. Which precaution would the nurse plan to implement? 1. Elopement precautions. 2. Suicide precautions. 3. Homicide precautions. 4. Fall precautions.

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2. Any client who is exhibiting hopelessness or helplessness needs to be monitored closely for suicide intentions. TEST-TAKING HINT: To answer this question correctly, the test taker should note the words "hopelessness" and "helplessness," which would be indications of suicidal ideations that warrant suicide precautions.

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A client diagnosed with obsessive-compulsive disorder has been hospitalized for the last 4 days. Which intervention would be a priority at this time? 1. Notify the client of the expected limitations on compulsive behaviors. 2. Reinforce the use of learned relaxation techniques. 3. Allow the client the time needed to complete the compulsive behaviors. 4. Say "stop" to the client as a thought-stopping technique.

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2. It is important for the client to learn techniques to reduce overall levels of anxiety to decrease the need for compulsive behaviors. The teaching of these techniques should begin by day 4. TEST-TAKING HINT: To answer this question correctly, the test taker must understand that nursing interventions should be based on timeframes appropriate to the expressed symptoms and severity of the client's disorder. The length of hospitalization also must be considered in planning these interventions. The average stay on an in-patient psychiatric unit is 5 to 7 days.

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The nurse on the in-patient psychiatric unit should include which of the following interventions when working with a newly admitted client diagnosed with obsessivecompulsive disorder? Select all that apply. 1. Assess previously used coping mechanisms and their effects on anxiety. 2. Allow time for the client to complete compulsions. 3. With the client's input, set limits on ritualistic behaviors. 4. Present the reality of the impact the compulsions have on the client's life. 5. Discuss client feelings surrounding the obsessions and compulsions.

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1. When a client is newly admitted, it is important for the nurse to assess past coping mechanisms and their effects on anxiety. Assessment is the first step in the nursing process, and this information needs to be gathered to intervene effectively. 2. Allowing time for the client to complete compulsions is important for a client who is newly admitted. If compulsions are limited, anxiety levels increase. If the client had been hospitalized for a while, then, with the client's input, limits would be set on the compulsive behaviors. 5. It is important for the nurse to allow the client to express his or her feelings about the obsessions and compulsions. This assessment of feelings should begin at admission. TEST-TAKING HINT: It is important for the test taker to note the words "newly admitted" in the question. The nursing interventions implemented vary and are based on length of stay on the unit, along with client's insight into his or her disorder. For clients with obsessive-compulsive disorder, it is important to understand that the compulsions are used to decrease anxiety. If the compulsions are limited, anxiety increases. Also, the test taker must remember that during treatment it is imperative that the treatment team includes the client in decisions related to any limitation of compulsive behaviors.

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A client diagnosed with generalized anxiety disorder complains of feeling out of control and states, "I just can't do this anymore." Which nursing action takes priority at this time? 1. Ask the client, "Are you thinking about harming yourself?" 2. Remove all potentially harmful objects from the milieu. 3. Place the client on a one-to-one observation status. 4. Encourage the client to verbalize feelings during the next group.

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1. The nurse should recognize the statement, "I can't do this anymore," as evidence of hopelessness and assess further the potential for suicidal ideations. TEST-TAKING HINT: To answer this question correctly, the test taker should apply the nursing process. Assessment is the first step of this process. The nurse initially must assess a situation before determining appropriate nursing interventions.

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During an intake assessment, a client diagnosed with generalized anxiety disorder rates mood at 3/10, rates anxiety at 8/10, and states, "I'm thinking about suicide." Which nursing intervention takes priority? 1. Teach the client relaxation techniques. 2. Ask the client, "Do you have a plan to commit suicide?" 3. Call the physician to obtain a PRN order for an anxiolytic medication. 4. Encourage the client to participate in group activities.

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2. It is important for the nurse to ask the client about a potential plan for suicide to intervene in a timely manner. Clients who have developed suicide plans are at higher risk than clients who may have vague suicidal thoughts. TEST-TAKING HINT: To answer this question correctly, the test taker must understand the importance of assessing the plan for suicide. Interventions would differ depending on the client's plan. The intervention for a plan to use a gun at home would differ from an intervention for a plan to hang oneself during hospitalization.

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A client diagnosed with posttraumatic stress disorder has a nursing diagnosis of disturbed sleep patterns R /T nightmares. Which evaluation would indicate that the stated nursing diagnosis was resolved? 1. The client expresses feelings about the nightmares during group. 2. The client asks for PRN trazodone (Desyrel) before bed to fall asleep. 3. The client states that the client feels rested when awakening and denies nightmares. 4. The client avoids napping during the day to help enhance sleep.

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3. The client's feeling rested on awakening and denying nightmares are the evaluation data needed to support the fact that the nursing diagnosis of disturbed sleep patterns R/T nightmares has been resolved. TEST-TAKING HINT: To answer this question correctly, the test taker needs to discern evaluation data that indicate problem resolution. Answers "1," "2," and "4" all are interventions to assist in resolving the stated nursing diagnosis, not evaluation data that indicate problem resolution.

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The nurse teaches an anxious client diagnosed with posttraumatic stress disorder a breathing technique. Which action by the client would indicate that the teaching was successful? 1. The client eliminates anxiety by using the breathing technique. 2. The client performs activities of daily living independently by discharge. 3. The client recognizes signs and symptoms of escalating anxiety. 4. The client maintains a 3/10 anxiety level without medications.

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4. A client's ability to maintain an anxiety level of 3/10 without medications indicates that the client is using breathing techniques successfully to reduce anxiety. TEST-TAKING HINT: To answer this question correctly, the test taker should understand that anxiety cannot be eliminated from life. This understanding would eliminate "1" immediately.

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The nurse is using a cognitive intervention to decrease anxiety during a client's panic attack. Which statement by the client would indicate that the intervention has been successful? 1. "I reminded myself that the panic attack would end soon, and it helped." 2. "I paced the halls until I felt my anxiety was under control." 3. "I felt my anxiety increase, so I took lorazepam (Ativan) to decrease it." 4. "Thank you for staying with me. It helped to know staff was there."

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1. This statement is an indication that the cognitive intervention was successful. By remembering that panic attacks are self-limiting, the client is applying the information gained from the nurse's cognitive intervention. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand which interventions support which theories of causation. When looking for a "cognitive" intervention, the test taker must remember that the theory involves thought processes.

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Which of the following medications can be used to treat clients with anxiety disorders? Select all that apply. 1. Clonidine hydrochloride (Catapres). 2. Fluvoxamine maleate (Luvox). 3. Buspirone (BuSpar). 4. Alprazolam (Xanax). 5. Haloperidol (Haldol).

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1. Clonidine hydrochloride (Catapres) is used in the treatment of panic disorders and generalized anxiety disorder. 2. Fluvoxamine maleate (Luvox) is used in the treatment of obsessive-compulsive disorder. 3. Buspirone (BuSpar) is used in the treatment of panic disorders and generalized anxiety disorders. 4. Alprazolam (Xanax), a benzodiazepine, is used for the short-term treatment of anxiety disorders. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand that many medications are used off-label to treat anxiety disorders.

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A client is prescribed alprazolam (Xanax) 2 mg bid and 1.5 mg q6h PRN for agitation. The maximum daily dose of alprazolam is 10 mg/d. The client can receive _____ PRN doses of alprazolam within a 24-hour period.

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The client can receive 4 PRN doses. Medications are given four times in a 24-hour period when the order reads q6h: 1.5 mg x 4 = 6 mg. The test taker must factor in 2 mg bid = 4 mg. These two dosages together add up to 10 mg, the maximum daily dose of alprazolam (Xanax), and so the client can receive all 4 PRN doses. TEST-TAKING HINT: To answer this question correctly, the test taker must recognize that the timing of standing medication may affect the decision- making process related to administration of PRN medications. In this case, the client would be able to receive all possible doses of PRN medication because the standing and PRN ordered medications together do not exceed the maximum daily dose.

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Which teaching need is important when a client is newly prescribed buspirone (BuSpar) 5 mg tid? 1. Encourage the client to avoid drinking alcohol while taking this medication because of the additive central nervous system depressant effects. 2. Encourage the client to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks. 3. Encourage the client to monitor for signs and symptoms of anxiety to determine need for additional buspirone (BuSpar) PRN. 4. Encourage the client to be compliant with monthly lab tests to monitor for medication toxicity.

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2. It is important to teach the client that the onset of action for buspirone (BuSpar) is 2 to 3 weeks. Often the nurse may see a benzodiazepine, such as clonazepam, prescribed because of its quick onset of effect, until the buspirone begins working. TEST-TAKING HINT: To answer this question correctly, the test taker must understand that buspirone (BuSpar) has a delayed onset of action, which can affect medication compliance. If the effects of the medication are delayed, the client is likely to stop taking the medication. Teaching about delayed onset is an important nursing intervention.

question

A client diagnosed with generalized anxiety disorder is prescribed paroxetine (Paxil) 30 mg QHS. Paroxetine is supplied as a 20-mg tablet. The nurse would administer ______tablets.

answer

1.5 tablets

question

A client is prescribed lorazepam (Ativan) 0.5 mg qid and 1 mg PRN q8h. The maximum daily dose of lorazepam should not exceed 4 mg QD. This client would be able to receive ______ PRN doses as the maximum number of PRN lorazepam doses.

answer

This client should receive 2 PRN doses. The test taker must recognize that medications are given three times in a 24-hour period when the order reads q8h: 1 mg x 3 = 3 mg. The test taker must factor in the 0.5 mg qid = 2 mg. These two dosages together add up to 5 mg, 1 mg above the maximum daily dose of lorazepam (Ativan). The client would be able to receive only two of the three PRN doses of lorazepam. TEST-TAKING HINT: To answer this question correctly, the test taker must recognize that the timing of standing medication may affect the decision-making process related to administration of PRN medications. In this case, although the PRN medication is ordered q8h, and could be given three times, the standing medication dosage limits the PRN to two doses, each at least 8 hours apart.

question

A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. "These clients do not recognize that their fear is excessive and rarely seek treatment." B. "These clients have a panic level of fear that is overwhelming and unreasonable." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."

answer

ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response.

question

A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia

answer

ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia which is a natural environment type of phobia. Natural environment-type phobias are fears about objects or situations that occur in the natural environment such as a fear of heights or storms.

question

How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

answer

ANS: C Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

question

How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.

answer

ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

question

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)

answer

ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

question

A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, how should a nurse explain to the spouse the etiology of this fear? A. "Your spouse may be unable to resolve internal conflicts which result in projected anxiety." B. "Your spouse may be experiencing a distorted and unrealistic appraisal of the situation." C. "Your spouse may have a genetic predisposition to overreacting to potential danger." D. "Your spouse may have high levels of brain chemicals that may distort thinking."

answer

ANS: B The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.

question

How would a nurse differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder? A. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not. B. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not. C. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions. D. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

answer

ANS: A A client diagnosed with OCD experiences both obsessions and compulsions. Clients diagnosed with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control.

question

A cab driver, stuck in traffic, suddenly is lightheaded, tremulous, diaphoretic, and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of anxiety

answer

ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden onset panic attacks in which the person feels intense fear, apprehension, or terror.

question

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing reply? A. "I know it's frightening, but try to remind yourself that this will only last a short time." B. "Death from a panic attack happens so infrequently that there is no need to worry." C. "Most people who experience panic attacks have feelings of impending doom." D. "Tell me why you think you are going to die every time you have a panic attack."

answer

ANS: A The most appropriate nursing reply to the client's concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.

question

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

answer

ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

question

A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing reply? A. "My mother also worries unnecessarily. I think it is part of the aging process." B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." C. "From what you have told me, you should get her to a psychiatrist as soon as possible." D. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."

answer

ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

question

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)

answer

ANS: C The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life and the presence of a trusted individual provides assurance of personal safety.

question

A college student is unable to take a final examination due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

answer

ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the client's healthy coping skills and reduce anxiety.

question

A client living on the beachfront seeks help with an extreme fear of crossing bridges which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. "Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge." B. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

answer

ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

question

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.

answer

ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.

question

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. "I will need scheduled blood work in order to monitor for toxic levels of this drug." B. "I won't stop taking this medication abruptly because there could be serious complications." C. "I will not drink alcohol while taking this medication." D. "I won't take extra doses of this drug because I can become addicted."

answer

ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

question

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization

answer

ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.

question

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

answer

ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions because they do not help the client recognize anxiety triggers.

question

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. "High doses of tricyclic medications will be required for effective treatment of OCD." B. "Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD." C. "The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia." D. "The dosage of Luvox is outside the therapeutic range and needs to be questioned."

answer

ANS: B The most accurate instructor response is that SSRI doses, in excess of what is effective for treating depression, may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

question

A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What short-term, realistic, correctly written outcome should be included in this client's plan of care? A. The client will have no flashbacks. B. The client will be able to feel a full range of emotions by discharge. C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. D. The client will refrain from discussing the traumatic event.

answer

ANS: C The nurse should include obtaining adequate sleep without zolpidem (Ambien) by discharge as a realistic outcome for this client. Having no flashbacks and experiencing a full range of emotions are long-term not short-term outcomes for this client. Clients are encouraged to discuss the traumatic event.

question

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension

answer

ANS: A The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.

question

A client diagnosed with post-traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that warrant the need for this medication? A. Flat affect and anhedonia B. Persistent anorexia and 10 lb weight loss in 3 weeks C. Flashbacks of killing the enemy D. Distant and guarded relationships

answer

ANS: C The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone (Invega). Paliperidone is an antipsychotic medication that can be used to treat the psychotic symptom of flashbacks.

question

Which nursing diagnosis would best describe the problems evidenced by the following client symptoms: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, emotional numbing, and flashbacks? A. Ineffective coping B. Post-trauma syndrome C. Complicated grieving D. Panic anxiety

answer

ANS: B Post-trauma syndrome is defined as a sustained maladaptive response to a traumatic, overwhelming event. This nursing diagnosis addresses the problems experienced by clients diagnosed with post-traumatic stress disorder.

question

How should a nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care due to physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.

answer

ANS: C The major maladaptive client response to panic disorder is the perception of having no control over life situations which leads to nonparticipation in decision making and doubts regarding role performance.

question

A client diagnosed with generalized anxiety states, "I know the best thing for me to do now is to just forget my worries." How should the nurse evaluate this statement? A. The client is developing insight. B. The client's coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.

answer

ANS: C This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.

question

A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose? A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions

answer

ANS: B Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system leading to respiratory arrest and death.

question

A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.) A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability

answer

ANS: A, D, E The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

question

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? (Select all that apply.) A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy

answer

ANS: B, C The nurse should explain to the client that systematic desensitization and imploding are the most commonly used behavioral therapies in the treatment of phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

question

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) A. Encourage the client to recognize the signs of escalating anxiety. B. Encourage the client to avoid any situation that causes stress. C. Encourage the client to employ newly learned relaxation techniques. D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. E. Encourage the client to avoid caffeinated products.

answer

ANS: A, C, D, E Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.

question

A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply.) A. The client has experienced symptoms of the disorder for 2 weeks. B. The client fears a physical integrity threat to self. C. The client feels detached and estranged from others. D. The client experiences fear and helplessness. E. The client is lethargic and somnolent.

answer

ANS: B, C, D Clients diagnosed with PTSD can experience the following symptoms: fear of a physical integrity threat to self, detachment and estrangement from others, and intense fear and helplessness. Characteristic symptoms of PTSD include re-living the traumatic event, a sustained high level of arousal, and a general numbing of responsiveness.

question

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. "You are very disrespectful. You need to learn to control yourself." B. "I understand that you are angry, but this behavior will not be tolerated." C. "What behaviors could you modify to improve this situation?" D. "What anti-personality-disorder medications have helped you in the past?"

answer

ANS: B The appropriate nursing statement is to reflect the client's feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the diagnosis of a personality disorder.

question

A client diagnosed with antisocial personality disorder comes to a nurses' station at 11:00 p.m. requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. "Go ahead and use the phone. I know this pending divorce is stressful." B. "You know better than to break the rules. I'm surprised at you." C. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow." D. "The decision to divorce should not be considered until you have had a good night's sleep."

answer

ANS: C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.

question

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence, that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the client's paranoid perceptions.

answer

ANS: C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

question

A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder

answer

ANS: C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.

question

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesman to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership.

answer

ANS: B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

question

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to society norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains

answer

ANS: A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction such as manipulation and splitting.

question

Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security

answer

ANS: C A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior.

question

A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of "suffering" in silence. Which underlying cause of this client's personality disorder should a nurse recognize? A. "Nurturance was provided from many sources, and independent behaviors were encouraged." B. "Nurturance was provided exclusively from one source, and independent behaviors were discouraged." C. "Nurturance was provided exclusively from one source, and independent behaviors were encouraged." D. "Nurturance was provided from many sources, and independent behaviors were discouraged."

answer

ANS: B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

question

Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. "Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone." B. "Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, while clients diagnosed with avoidant personality disorder do not." C. "Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant." D. "Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, while clients diagnosed with avoidant personality disorder remain based in reality."

answer

ANS: A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.

question

During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. "I really don't have a problem. My family is inflexible, and every relative is out to get me." B. "I am so excited about working with you. Have you noticed my new nail polish: 'Ruby Red Roses'?" C. "I spend all my time tending my bees. I know a whole lot of information about bees." D. "I am getting a message from the beyond that we have been involved with each other in a previous life."

answer

ANS: D The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

question

A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. "Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling." B. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." C. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection." D. "They pay particular attention to details which can frustrate the development of relationships."

answer

ANS: B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.

question

Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

answer

ANS: D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.

question

When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body

answer

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.

question

Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and whispers, "The night nurse is evil. You have to stay." B. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me." C. As the day shift nurse leaves the unit, the client suddenly hugs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here." D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

answer

ANS: D The client who states, "I cut myself because you are leaving me" reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.

question

Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others

answer

ANS: A The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior.

question

From a behavioral perspective, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues.

answer

ANS: B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

question

A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? A. "You really don't have to go by that schedule. I'd just stay home sick." B. "There has got to be a hidden agenda behind this schedule change." C. "Who do you think you are? I expect to interact with the same nurse every Saturday." D. "You can't make these kinds of changes! Isn't there a rule that governs this decision?"

answer

ANS: D The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, over disciplined, perfectionistic, and preoccupied with rules.

question

Looking at a slightly bleeding paper cut, the client screams, "Somebody help me, quick! I'm bleeding. Call 911!" A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

answer

ANS: C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive.

question

Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment

answer

ANS: C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

question

Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed.

answer

ANS: C The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

question

Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder

answer

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.

question

When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites

answer

ANS: C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.

question

The nurse plans to confront a client about secondary gains related to extreme dependency on spouse. Which nursing statement would be most appropriate? A. "Do you believe dependency issues have been a lifelong concern for you?" B. "Have you noticed any anxiety during times when your husband makes decisions." C. "What do you know about individuals who depend on others for direction?" D. "How have the specifics of your relationship with your spouse benefited you?"

answer

ANS: D When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that the client might not otherwise receive.

question

The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis.

answer

ANS: B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis.

question

Which client statement would demonstrate a common characteristic of Cluster "B" personality disorder? A. "I wish someone would make that decision for me." B. "I built this building by using materials from outer space." C. "I'm afraid to go to group because it is crowded with people." D. "I didn't have the money for the ring, so I just took it."

answer

ANS: D Antisocial personality disorder is included in the Cluster "B" personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.

question

When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes? A. Provide external limits on client behavior. B. Foster discussions of rationales for behavioral change. C. Implement interventions consistently by only one staff member. D. Encourage the client to involve self in care.

answer

ANS: A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff.

question

Which characteristics should a nurse recognize as being exhibited by individuals diagnosed with any personality disorders? A. These clients accept and are comfortable with their altered behaviors. B. These clients understand that their altered behaviors result from anxiety. C. These clients seek treatment to avoid interpersonal discomfort. D. These clients avoid relationships due to past negative experiences.

answer

ANS: A Clients who are diagnosed with personality disorders accept and are comfortable with their altered behaviors. Personalities that develop in a disordered pattern remain somewhat unstable and unpredictable throughout the lifetime.

question

A nurse would expect a client diagnosed with schizotypal personality disorder to exhibit which characteristic? A. The client keeps to self and has few, if any relationships. B. The client has many brief but intense relationships. C. The client experiences incorrect interpretations of external events. D. The client exhibits lack of tender feelings toward others.

answer

ANS: C Clients who are diagnosed with schizotypal personality disorder experience odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms. This results in incorrect interpretations of external events.

question

While improving, a client demands to have a phone installed in the intensive care unit (ICU) room. When a nurse states, "This is not allowed. It is a unit rule." The client angrily demands to see the doctor. Which approach should the nurse use in this situation? A. Provide an explanation for the necessity of the unit rule. B. Assist the client to discuss anger and frustrations. C. Call the physician and relay the request. D. Arrange for a phone to be installed in the client's unit room.

answer

ANS: B Clients who demand special privileges may be diagnosed with narcissistic personality disorder. The best approach in this situation is for the nurse to identify the function that anger, frustration, and rage serve for the client. The verbalization of feelings may help the client to gain insight into his or her behavior.

question

Which nursing statement reflects a common characteristic of a client diagnosed with paranoid personality disorder? A. "This client consistently criticizes care and has difficulty getting along with others." B. "This client is shy and fades into the background." C. "This client expects special treatment and setting limits will be necessary." D. "This client is expressive during group and is very pleased with self."

answer

ANS: A A client diagnosed with paranoid personality disorder has a pervasive distrust and suspiciousness of others. Anticipating humiliation and betrayal, the paranoid individual characteristically learns to attack first.

question

A client exhibits dependency on staff and peers and expresses fear of abandonment. Using Mahler's theory of object relations, which should the nurse expect to note in this client's childhood? A. Lack of fulfillment of basic needs by parental figures B. Absence of the client's maternal figure during symbiosis C. Difficulty establishing trust with the maternal figure D. Inconsistency by the maternal figure during individuation

answer

ANS: D During phase 3 (5 to 36 months) of Margaret Mahler's individuation theory, there should be a strengthening of the ego and an acceptance of "self" with independent ego boundaries. Inconsistency by the maternal figure during individuation may in later years result in feelings of helplessness when the client is alone because of exaggerated fears of being unable to care for self.

question

A client diagnosed with cluster "C" traits sits alone and ignores other's attempts to converse. When ask to join a group the client states, "No thanks." In this situation, which should the nurse assign as an initial nursing diagnosis? A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues

answer

ANS: B Clients diagnosed with cluster "C" traits are described as anxious and fearful. The DSM-IV-TR divides cluster "C" personality disorders into three categories: avoidant, dependent, and obsessive-compulsive. Anxiety and fear contribute to social isolation.

question

Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.) A. The client will relate one empathetic statement toward another client in group by day 2. B. The client will identify one personal limitation by day 1. C. The client will acknowledge one strength that another client possesses by day 2. D. The client will list four personal strengths by day 3. E. The client will list two lifetime achievements by discharge.

answer

ANS: A, B, C The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. An exaggerated sense of self-worth, a lack of empathy, and exploitation of others are characteristics of narcissistic personality disorder.

question

A nurse is caring for a group of clients within the DSM-IV-TR cluster B category of personality disorders. Which factors should the nurse consider when planning client care? (Select all that apply.) A. These clients have personality traits that are deeply ingrained and difficult to modify. B. These clients need medications to treat the underlying physiological pathology. C. These clients use manipulation, making the implementation of treatment problematic. D. These clients have poor impulse control that hinders compliance with a plan of care. E. These clients commonly have secondary diagnoses of substance abuse and depression.

answer

ANS: A, C, D, E The nurse should consider that individuals diagnosed with cluster B-type personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

question

A client is diagnosed with dysthymic disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

answer

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymic disorder. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological.

question

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

answer

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

question

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

answer

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-IV-TR, these symptoms would rule out the diagnosis of major depressive disorder.

question

A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

answer

ANS: A According to the DSM-IV-TR, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level which results from a low thyroid function or hypothyroidism. In hypothyroidism, metabolic processes are slowed leading to depressive symptoms.

question

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms? A. According to psychoanalytic theory, depression is a result of anger turned inward. B. According to object-loss theory, depression is a result of abandonment. C. According to learning theory, depression is a result of repeated failures. D. According to cognitive theory, depression is a result of negative perceptions.

answer

ANS: C The nurse should assess that this client's depressive symptoms may have resulted from repeated failures. This assessment was based on the principles of learning theory. Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

question

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression can generate somatic symptoms that can mask actual physical disorders. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

answer

ANS: B The nurse should determine that a client with a diagnosis of major depressive disorder needs a full physical health assessment because depression can generate somatic symptoms that can mask actual physical disorders. Somatization is the process by which psychological needs are expressed in the form of physical symptoms.

question

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

answer

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

question

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out senile dementia D. To rule out a personality disorder

answer

ANS: C A mini-mental status exam should be performed to rule out senile dementia. The elderly are often misdiagnosed with senile dementia when depression is their actual diagnosis. Memory loss, confused thinking, or apathy symptomatic of dementia actually may be the result of depression.

question

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

answer

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

question

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

answer

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

question

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

answer

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

question

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

answer

ANS: B Buspar takes at least 2 to 3 weeks to be effective in controlling symptoms of depression. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

question

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

answer

ANS: A A client diagnosed with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

question

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

answer

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be firmly directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

question

Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.

answer

ANS: C Zoloft is a selective serotonin reuptake inhibitor (SSRI) that has a relatively benign side effect profile as compared with other antidepressants.

question

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular blood work B. The client's mood and affect score, using the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

answer

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

question

A client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

answer

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. The diagnosis of SAD is not associated with a traumatic event.

question

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

answer

ANS: B Often suicidal clients resist personal monitoring which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

question

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.

answer

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe based on assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

question

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

answer

ANS: C When a nurse assesses and attempts to modify negative thought patterns related to depressive symptoms, the nurse is using a cognitive theory framework.

question

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."

answer

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. Depressive symptoms are often described as anger turned inward.

question

A 75-year-old client diagnosed with a long history of depression is currently on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

answer

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

question

A client is admitted with a diagnosis of depression NOS (not otherwise specified). Which client statement would describe a somatic symptom that can occur with this diagnosis? A. "I am extremely sad, but I don't know why." B. "Sometimes I just don't want to eat because I ache all over." C. "I feel like I can't ever make the right decision." D. "I can't seem to leave the house without someone with me."

answer

ANS: B When a client diagnosed with depression expresses physical complaints, the client is experiencing somatic symptoms. Somatic symptoms occur with depression because of a general slowdown of the entire body reflected in sluggish digestion, constipation, impotence, anorexia, difficulty falling asleep, and a wide variety of other symptoms.

question

A client diagnosed with major depressive disorder was raised in an excessively religiously based household. Which nursing intervention would be most appropriate to address this client's underlying problem? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

answer

ANS: A A client raised in an excessively religiously based household maybe at risk for experiencing guilt to the point of accepting liability in situations for which one is not responsible. The client may view himself or herself as evil and deserving of punishment leading to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

question

A nurse is caring for four clients taking various medications including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

answer

ANS: D Hypertensive crisis occurs in clients receiving monoamine oxidase inhibitor (MAOI) who consume foods or drugs high in tyramine content.

question

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Expressions of poor self-esteem

answer

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Depressed clients do not care enough about themselves to participate in grooming and hygiene.

question

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "I'm glad you shared this. There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

answer

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

question

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) A. Sad mood on most days B. Mood rating of 2/10 for the past 6 months C. Labile mood D. Sad mood for the past 3 years after spouse's death E. Pressured speech when communicating

answer

ANS: A, D The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than 2 years. The essential feature of dysthymia is a chronically depressed mood which can have an early or late onset.

question

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

answer

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

question

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

answer

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs due to the risk of drug interactions.

question

A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. "These clients do not recognize that their fear is excessive and rarely seek treatment." B. "These clients have a panic level of fear that is overwhelming and unreasonable." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."

answer

ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response.

question

A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia

answer

ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia which is a natural environment type of phobia. Natural environment-type phobias are fears about objects or situations that occur in the natural environment such as a fear of heights or storms.

question

How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

answer

ANS: C Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

question

How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.

answer

ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

question

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)

answer

ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

question

A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, how should a nurse explain to the spouse the etiology of this fear? A. "Your spouse may be unable to resolve internal conflicts which result in projected anxiety." B. "Your spouse may be experiencing a distorted and unrealistic appraisal of the situation." C. "Your spouse may have a genetic predisposition to overreacting to potential danger." D. "Your spouse may have high levels of brain chemicals that may distort thinking."

answer

ANS: B The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.

question

How would a nurse differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder? A. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not. B. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not. C. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions. D. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

answer

ANS: A A client diagnosed with OCD experiences both obsessions and compulsions. Clients diagnosed with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control.

question

A cab driver, stuck in traffic, suddenly is lightheaded, tremulous, diaphoretic, and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of anxiety

answer

ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden onset panic attacks in which the person feels intense fear, apprehension, or terror.

question

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing reply? A. "I know it's frightening, but try to remind yourself that this will only last a short time." B. "Death from a panic attack happens so infrequently that there is no need to worry." C. "Most people who experience panic attacks have feelings of impending doom." D. "Tell me why you think you are going to die every time you have a panic attack."

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ANS: A The most appropriate nursing reply to the client's concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.

question

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

answer

ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

question

A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing reply? A. "My mother also worries unnecessarily. I think it is part of the aging process." B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." C. "From what you have told me, you should get her to a psychiatrist as soon as possible." D. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."

answer

ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

question

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)

answer

ANS: C The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life and the presence of a trusted individual provides assurance of personal safety.

question

A college student is unable to take a final examination due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

answer

ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the client's healthy coping skills and reduce anxiety.

question

A client living on the beachfront seeks help with an extreme fear of crossing bridges which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. "Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge." B. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

answer

ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

question

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.

answer

ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.

question

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. "I will need scheduled blood work in order to monitor for toxic levels of this drug." B. "I won't stop taking this medication abruptly because there could be serious complications." C. "I will not drink alcohol while taking this medication." D. "I won't take extra doses of this drug because I can become addicted."

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ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

question

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization

answer

ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.

question

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

answer

ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions because they do not help the client recognize anxiety triggers.

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A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. "High doses of tricyclic medications will be required for effective treatment of OCD." B. "Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD." C. "The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia." D. "The dosage of Luvox is outside the therapeutic range and needs to be questioned."

answer

ANS: B The most accurate instructor response is that SSRI doses, in excess of what is effective for treating depression, may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

question

A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What short-term, realistic, correctly written outcome should be included in this client's plan of care? A. The client will have no flashbacks. B. The client will be able to feel a full range of emotions by discharge. C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. D. The client will refrain from discussing the traumatic event.

answer

ANS: C The nurse should include obtaining adequate sleep without zolpidem (Ambien) by discharge as a realistic outcome for this client. Having no flashbacks and experiencing a full range of emotions are long-term not short-term outcomes for this client. Clients are encouraged to discuss the traumatic event.

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A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension

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ANS: A The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.

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A client diagnosed with post-traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that warrant the need for this medication? A. Flat affect and anhedonia B. Persistent anorexia and 10 lb weight loss in 3 weeks C. Flashbacks of killing the enemy D. Distant and guarded relationships

answer

ANS: C The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone (Invega). Paliperidone is an antipsychotic medication that can be used to treat the psychotic symptom of flashbacks.

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Which nursing diagnosis would best describe the problems evidenced by the following client symptoms: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, emotional numbing, and flashbacks? A. Ineffective coping B. Post-trauma syndrome C. Complicated grieving D. Panic anxiety

answer

ANS: B Post-trauma syndrome is defined as a sustained maladaptive response to a traumatic, overwhelming event. This nursing diagnosis addresses the problems experienced by clients diagnosed with post-traumatic stress disorder.

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How should a nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care due to physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.

answer

ANS: C The major maladaptive client response to panic disorder is the perception of having no control over life situations which leads to nonparticipation in decision making and doubts regarding role performance.

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A client diagnosed with generalized anxiety states, "I know the best thing for me to do now is to just forget my worries." How should the nurse evaluate this statement? A. The client is developing insight. B. The client's coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.

answer

ANS: C This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.

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A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose? A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions

answer

ANS: B Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system leading to respiratory arrest and death.

question

A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.) A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability

answer

ANS: A, D, E The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

question

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? (Select all that apply.) A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy

answer

ANS: B, C The nurse should explain to the client that systematic desensitization and imploding are the most commonly used behavioral therapies in the treatment of phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

question

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) A. Encourage the client to recognize the signs of escalating anxiety. B. Encourage the client to avoid any situation that causes stress. C. Encourage the client to employ newly learned relaxation techniques. D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. E. Encourage the client to avoid caffeinated products.

answer

ANS: A, C, D, E Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.

question

A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply.) A. The client has experienced symptoms of the disorder for 2 weeks. B. The client fears a physical integrity threat to self. C. The client feels detached and estranged from others. D. The client experiences fear and helplessness. E. The client is lethargic and somnolent.

answer

ANS: B, C, D Clients diagnosed with PTSD can experience the following symptoms: fear of a physical integrity threat to self, detachment and estrangement from others, and intense fear and helplessness. Characteristic symptoms of PTSD include re-living the traumatic event, a sustained high level of arousal, and a general numbing of responsiveness.

question

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader

answer

ANS: C The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients in communicating needs and maintaining connectedness.

question

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."

answer

ANS: C The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content. It is inappropriate to present logical arguments to persuade the client to accept the hallucinations as not real.

question

A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing? A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference

answer

ANS: D The nurse is assessing for the potential symptom of delusions of reference. A client who believes that he or she receives messages through the radio is experiencing delusions of reference. When a client experiences these delusions, he or she interprets all events within the environment as personal references.

question

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur

answer

ANS: B The nurse is assessing the client for delusions of influence when asking if the client has ever felt that objects or persons have control of the client's behavior. Delusions of control or influence are manifested when the client believes that his or her behavior is being influenced. An example would be if a client believes that a hearing aid receives transmissions that control personal thoughts and behaviors.

question

Which statement should indicate to a nurse that an individual is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."

answer

ANS: A The nurse should recognize that a client who claims that an alien is inside his or her body is experiencing a delusion. Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background.

question

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom

answer

ANS: C The nurse should expect the physician to order risperidone (Risperdal) to address the positive symptoms of schizophrenia. Risperidone (Risperdal) is an atypical antipsychotic used to reduce positive symptoms, including disturbances in content of thought (delusions), form of thought (neologisms), or sensory perception (hallucinations).

question

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices

answer

ANS: C The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic medication such as haloperidol. An anticholinergic medication such as benztropine would be used to treat the extrapyramidal symptoms of restlessness and muscle rigidity.

question

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

answer

ANS: B The nurse should recognize that positive symptoms of schizophrenia include paranoid delusions, neologisms, and echolalia. The negative symptoms of schizophrenia include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a decrease or loss of normal functions.

question

A client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing antipsychotic medications B. Agranulocytosis and treat by administration of clozapine (Clozaril) C. Extrapyramidal symptoms and treat by administration of benztropine (Cogentin) D. Tardive dyskinesia and treat by discontinuing antipsychotic medications

answer

ANS: D The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be an irreversible side effect of typical antipsychotic medications.

question

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5C). The nurse expects the physician to recognize which condition and implement which treatment? A. Neuroleptic malignant syndrome and treat by discontinuing Thorazine and administering dantrolene (Dantrium) B. Neuroleptic malignant syndrome and treat by increasing Thorazine dosage and administering an antianxiety medication C. Dystonia and treat by administering trihexyphenidyl (Artane) D. Dystonia and treat by administering bromocriptine (Parlodel)

answer

ANS: A The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics due to fewer side effects and lower risks.

question

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention

answer

ANS: A The nurse should intervene immediately if the client experiences a sore throat, fever, and malaise when taking the atypical antipsychotic drug clozapine (Clozaril). Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. Symptoms of infectious processes would alert the nurse to this potential.

question

If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect? A. White blood cell count B. Liver function studies C. Creatinine clearance D. Blood urea nitrogen

answer

ANS: A The nurse should establish a baseline white blood cell count to evaluate a potentially life-threatening side effect if clozapine (Clozaril) is being considering as a treatment option. Clozapine can have a serious side effect of agranulocytosis in which a potentially fatal drop in white blood cells can occur.

question

During an admission assessment, a nurse notes that a client diagnosed with schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

answer

ANS: D The nurse should know that thioridazine (Mellaril) would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine (Compazine) and thioridazine are both classified as phenothiazines.

question

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? (Select all that apply.) A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

answer

ANS: A, B, D, E The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part in rehabilitative programs for clients diagnosed with schizophrenia. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

question

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? (Select all that apply.) A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations

answer

ANS: A, C, E The nurse should expect that risperidone (Risperdal) would be effective treatment for somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

question

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia. When assessing the client, which symptoms should a nurse expect to observe?(Select all that apply.) A. Apathy B. Social withdrawal C. Anhedonia D. Auditory hallucinations E. Delusions

answer

ANS: A, B, C The nurse should expect that a client with decreased levels of prolactin would experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression which would result in the above symptoms.

question

Typical Antipsychotics (8)

answer

Haloperidol Loxapine Thioridazine Fluphenazine Trifluoperazine Chlorpromazine Perphenazine Thiothixene

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Typical Antipsychotic

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Haloperidol

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Typical Antipsychotic

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Loxapine

question

Typical Antipsychotic

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Thioridazine

question

Typical Antipsychotic

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Fluphenazine

question

Typical Antipsychotic

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Trifluoperazine

question

Typical Antipsychotic

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Chlorpromazine

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Typical Antipsychotic

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Perphenazine

question

Typical Antipsychotic

answer

Thiothixene

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Atypical Antipsychotics

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Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Paliperidone Iloperidone Asenapine Lurasidone Cariprazine Brexiprazole

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Atypical Antipsychotic

answer

Clozapine

question

Atypical Antipsychotics

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Risperidone

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Atypical Antipsychotics

answer

Olanzapine

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Atypical Antipsychotics

answer

Quetiapine

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Atypical Antipsychotics

answer

Ziprasidone

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Atypical Antipsychotics

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Aripiprazole

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Atypical Antipsychotics

answer

Paliperidone

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Atypical Antipsychotics

answer

Iloperidone

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Atypical Antipsychotics

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Asenapine

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Atypical Antipsychotics

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Lurasidone

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Atypical Antipsychotics

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Cariprazine

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Atypical Antipsychotics

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Brexpiprazole

question

Which data gathering technique is employed during the assessment phase of the nursing process? A. Asking the client to rate mood after administering an antidepressant B. Asking the client to verbalize understanding of previously explained unit rules C. Asking the client to describe any thoughts of self-harm D. Asking the client if the group on assertiveness skills was helpful

answer

ANS: C The nurse should ask the client to describe any thoughts of self-harm during the assessment phase of the nursing process. Assessment involves collecting and analyzing data about the client that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities. The other three options are employed during the evaluation phase of the nursing process.

question

Which statement is most accurate regarding the assessment of clients diagnosed with psychiatric problems? A. Medical history is of little significance and can be eliminated from the nursing assessment. B. Assessment provides a holistic view of the client including biopsychosocial aspects. C. Comprehensive assessments can be performed only by advanced practice nurses. D. Psychosocial evaluations are gained by subjective reports rather than objective observations.

answer

ANS: B The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health-care providers that may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, developmental, economic, lifestyle, and functional abilities.

question

Which nursing diagnosis should a nurse identify as being correctly formulated? A. Schizophrenia R/T biochemical alterations AEB altered thought B. Self-care deficit: hygiene R/T altered thought as AEB disheveled appearance C. Depressed mood R/T multiple life stressors D. Developmental disability R/T early-onset schizophrenia AEB hallucinations

answer

ANS: B The nurse should determine that the correctly written diagnosis would be Self-care deficit: hygiene R/T altered thought AEB disheveled appearance. The nursing diagnosis should describe the client's condition, facilitating the choice of interventions.

question

Which expected client outcome should a nurse identify as being correctly formulated? A. Client will feel happier by discharge. B. Client will demonstrate two relaxation techniques. C. Client will verbalize triggers to anger by end of session. D. Client will initiate interaction with one peer during free time within 2 days.

answer

ANS: D The statement "Client will initiate interaction with one peer during free time within 2 days." is an example of a correctly formulated expected outcome. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

question

Which statement regarding nursing interventions should a nurse identify as accurate? A. Nursing interventions are independent from the treatment team's goals. B. Nursing interventions are solely directed by written physician orders. C. Nursing interventions occur independently but in concert with overall treatment team goals. D. Nursing interventions are standardized by policies and procedures.

answer

ANS: C The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care.

question

Within the nurse's scope of practice, which function is exclusive to the advance practice psychiatric nurse? A. Teaching about the side effects of neuroleptic medications B. Using psychotherapy to improve mental health status C. Using milieu therapy to structure a therapeutic environment D. Providing case management to coordinate continuity of health services

answer

ANS: B The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. It is within the scope of practice of a registered psychiatric mental health nurse generalist to provide education, case management, and milieu therapy.

question

A nurse charts "Verbalizes understanding of the side effects of Prozac." This is an example of which category of focused charting? A. Data B. Problem C. Action D. Response

answer

ANS: D "Verbalizes understanding of the side effects of Prozac." is an example of the response category of focused charting. The response is a description of the client's reaction to any part of medical or nursing care.

question

The nurse should recognize which acronym as representing problem-oriented charting? A. SOAPIE B. APIE C. DAR D. PQRST

answer

ANS: A The acronym SOAPIE represents problem-oriented charting which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. This type of charting identifies nursing diagnoses (client problems) on a written plan of care with appropriate nursing interventions described for each.

question

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)? A. CIWA scale B. GGT C. MMSE D. CAPS scale

answer

ANS: C The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdrawal from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is used to assess gamma-glutamyl transferase levels which may be an indication of alcoholism.

question

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation? A. Mood B. Perception C. Orientation D. Affect

answer

ANS: C The nurse should ask the client to identify name, date, residential address, and situation to assess the client's orientation. Assessment of the client's orientation to reality is part of a mental status evaluation.

question

What is the purpose when a nurse gathers client information? A. It enables the nurse to modify client behaviors related to personality disorders. B. It enables the nurse to make sound clinical judgments and plan appropriate client care. C. It enables the nurse to prescribe the appropriate medications. D. It enables the nurse to assign the appropriate Axis I diagnosis.

answer

ANS: B The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care. The nurse should complete a thorough assessment of the client including information collected from the client, significant others, and health-care providers.

question

A nurse on an inpatient psychiatric unit implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. These actions reflect which role of the nurse? A. Health teacher B. Case manager C. Milieu manager D. Psychotherapist

answer

ANS: C The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment. Health teaching involves promoting health and a safe environment. Case management is utilized to organize client care so that outcomes are achieved. Psychotherapy involves conducting individual, couples, group, and family counseling.

question

The following outcome was developed for a client: "Client will list five personal strengths by the end of day 1." Which correctly written nursing diagnostic statement most likely generated the development of this outcome? A. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements B. Self-care deficit R/T altered thought processes C. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10 D. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt

answer

ANS: A The nurse should determine that altered self-esteem and self-deprecating statements would generate the outcome to list personal strengths by the end of day 1. Self-care deficit, disturbed body image, and risk for disturbed self-concept would generate specific outcomes in accordance with specific needs and goals. The self-care deficit and risk for disturbed self-concept nursing diagnoses are incorrectly written.

question

How should a nurse prioritize nursing diagnoses? A. By the established goal of care B. By the life-threatening potential C. By the physician's priority of care D. By the client's preference

answer

ANS: B The nurse should prioritize nursing diagnoses related to life-threatening potential. Safety is always the nurse's first priority.

question

A client has a nursing diagnosis of Insomnia R/T paranoid thinking AEB midnight awakenings, difficulty falling asleep, and daytime napping. Which is a correctly written and appropriate outcome for this client's problem? A. The client will avoid daytime napping and attend all groups. B. The client will exercise, as needed, before bedtime. C. The client will sleep 7 uninterrupted hours by day four of hospitalization. D. The client's sleep habits will improve during hospitalization.

answer

ANS: C The outcome "The client will sleep 7 uninterrupted hours by day four of hospitalization." is accurately written and an appropriate outcome to address the client problem of insomnia. Outcomes should be measurable, realistic, client-focused goals that include a time frame. Appropriate nursing interventions are guided by client outcomes.

question

The following North American Nursing Diagnosis Association (NANDA) nursing diagnostic stem was developed for a client on an inpatient unit: Risk for injury. What assessment data most likely led to the development of this problem statement? A. The client is receiving electroconvulsive therapy (ECT) and is diagnosed with Parkinsonism. B. The client has a history of four suicide attempts in adolescence. C. The client expresses hopelessness and helplessness and isolates self. D. The client has disorganized thought processes and delusional thinking.

answer

ANS: A The nurse should identify that a client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury due to confusion and potential for falls. History of suicide and hopelessness would lead to the development of a risk for suicide nursing diagnosis. Disorganized thoughts and delusional thinking would lead to the development of an altered thought process nursing diagnosis.

question

A student nurse asks an instructor how best to develop nursing outcomes for clients. Which reply by the instructor most accurately answers the student's question? A. "Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes." B. "Look at your client's problems and set a realistic, achievable goal." C. "Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes." D. "Copy your standard outcomes from a nursing care plan textbook."

answer

ANS: C NOC is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of nursing interventions.

question

A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that the client is hearing things that others do not. Which nursing diagnosis accurately reflects this client's problem? A. Altered thought processes B. Altered sensory perception C. Anxiety D. Chronic confusion

answer

ANS: B The nursing diagnosis altered sensory perception accurately reflects the client's symptoms of hearing things that others do not. A nursing diagnosis describes a client's condition and facilitates the prescription of interventions. Delusional thinking, confusion, and disorientation are problems associated with the nursing diagnosis of altered thought processes.

question

A nurse is evaluating the effectiveness of teaching after instructing a group of clients on joint replacement. In the evaluation step of the nursing process, which learning domain is the most difficult to measure? A. Normative domain B. Affective domain C. Cognitive domain D. Psychomotor domain

answer

ANS: B Affective knowledge is the most difficult to evaluate because of differences in values, cultures, and attitudes.

question

A client is recovering from abdominal surgery. In order to maximize the learning process prior to discharge teaching, which assessment should be performed by the nurse? A. Assessing the client's level of pain B. Assessing and documenting the client's vital signs C. Assessing skin turgor and hydration status D. Assessing incisional site for serosanguineous drainage

answer

ANS: A Pain will distract the client and interfere with the learning process.

question

During the implementation phase of the nursing process, a nurse is teaching an adult with a cochlear implant about medications. Which modification in the teaching plan would be the most appropriate for this client? A. Using repetition B. Speaking directly face-to-face C. Employing the use of sign language D. Providing large-print materials

answer

ANS: B Speaking face-to-face is an appropriate way to teach individuals with alterations in hearing.

question

A client who has slept 6 hours the previous night reports this to the assigned psychiatric nurse. What should be the initial nursing action to address this situation? A. Provide warm milk and a backrub. B. Give a sleep medication. C. Hold a relaxation group before bedtime. D. Review the client's normal sleep pattern.

answer

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, the nurse must initially determine the client's normal sleep patterns in order to evaluate if a true problem exists.

question

An instructor overhears a student say, "That family seems to disagree more than agree. The family seems to be dysfunctional." To further assess the family's situation, which would be an appropriate instructor reply? A. "Families who disagree can be a challenge to the treatment team." B. "You seem very critical of the family. Do you believe that you are unable to help them?" C. "Let's bring the family in for an educational session to improve their communication." D. "What appears to trigger family disagreements?"

answer

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. In this situation, prior to intervening with this family, the nurse needs further information about the cause of family conflicts.

question

Which nursing response would be appropriately used in the evaluation phase of the nursing process? A. "If I were in your situation, I would not repeat a behavior that has caused problems." B. "What do you think needs changing, and what do you want to do differently?" C. "What exactly will it take to carry out your plan, and what else do you need to do?" D. "This new approach seems to work for you."

answer

ANS: D In the evaluation phase of the nursing process, the nurse evaluates progress toward attainment of the expected outcomes.

question

A client diagnosed with major depressive disorder states, "Why should I keep trying to get a job? I mess up everything I do." Which correctly written nursing diagnosis best reflects the content and mood themes in this client's statement? A. Hopelessness R/T poor job performance B. Risk for impaired adjustment R/T inadequate social skills AEB isolation C. Altered role performance R/T the fear of failure AEB not seeking employment D. Chronic low self-esteem R/T major depressive disorder AEB self-hatred

answer

ANS: C An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it doesn't as of yet exist. The client's statement indicates that role performance is altered due to the fact that fear of failure prevents seeking employment.

question

During an intake interview, which question would assist the nurse in gathering data about the client's judgment? A. "What brought you to the hospital? Do you know what day and season it is now?" B. "On a scale of 1 to 10, how would you rate your stress level?" C. "What does the phrase 'a rolling stone gathers no moss' mean to you?" D. "If you found a stamped, addressed envelope in the street, what would you do?"

answer

ANS: D In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. The nurse presents a situation that requires the client to make a judgment call and can assess appropriate judgment based on the client's action choice.

question

An adolescent client has problems expressing anger appropriately. Which nursing statement would encourage the client to set realistic goals? A. "What do you think needs to change about how you express anger?" B. "How did you feel after attending the anger management session?" C. "On a scale of 1 to 10, please rate your current level of anger." D. "What bothers you about the actions of others when you get angry?"

answer

ANS: A In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client or to the situation.

question

The nurse interviewed a client who was uncooperative, answered questions with minimal responses, and rarely made eye contact. Which is the most complete documentation of baseline data obtained during the interview? A. "Appears uncooperative. Exhibits characteristics of depression." B. "Maintains poor eye contact throughout interview process. Unable to answer interview questions due to depression." C. "States, 'I don't need to be here.' when discussing admission status. Maintains minimal eye contact and offers little data related to triggers for admission." D. "Unwilling to respond openly during interview."

answer

ANS: C Documentation occurs in the implementation phase of the nursing process. All charting entries to the client's legal record should be objective and based on assessed data. Implications and generalizations should be avoided.

question

A client is assigned the nursing diagnosis of impaired social interaction R/T socio-cultural differences AEB client stating, "Although I'd like to, I don't join in because I don't speak the language so good." Which correctly written outcome addresses this client's problem? A. The client will collaborate with nursing staff to set specific goals by day 3. B. The client will participate in one group activity of choice by day 2. C. The client will express a desire to interact with others. D. The client will become increasingly independent by discharge.

answer

ANS: B In the planning phase of the nursing process, the nurse works with the client to identify expected outcomes for a plan individualized to the client need or to the situation.

question

The following clients are seen in the emergency department. The psychiatric unit has one remaining bed. The triage nurse should expect which client to be admitted? A. The client who is experiencing tremors and has a need for medication adjustment B. The client who is experiencing anxiety and a sad mood after separation from spouse C. The client who is a single parent and hears voices stating, "Kill your infant son" D. The client who argued with her boyfriend and inflicted a superficial cut on her arm

answer

ANS: C In the assessment phase of the nursing process, the nurse collects comprehensive health data that are pertinent to the client's health or situation. These data are prioritized to meet client needs with an emphasis on safety.

question

Which of the following nursing interventions fall within the standards of psychiatric-mental health clinical nursing practice for a nurse generalist? (Select all that apply.) A. Assist clients to perform activities of daily living. B. Consult with other clinicians to provide services for clients and effect system change. C. Encourage clients to discuss triggers for relapse. D. Use prescriptive authority in accordance with state and federal laws. E. Educate families about signs and symptoms of alcohol dependence and withdrawal.

answer

ANS: A, C, E Assisting clients to perform daily living activities, encouraging clients to discuss triggers, and educating families are nursing interventions that fall within the standards of psychiatric clinical nursing practice for a nurse generalist. Psychiatric-mental health advanced practice registered nurses can consult with other clinicians and use prescriptive authority.

question

Which of the following characteristics of accurately developed client outcomes should a nurse identify? (Select all that apply.) A. Client outcomes are specifically formulated by nurses. B. Client outcomes are not restricted by time frames. C. Client outcomes are specific and measurable. D. Client outcomes are realistically based on client capability. E. Client outcomes are formally approved by the psychiatrist.

answer

ANS: C, D The nurse should identify that client outcomes should be specific, measurable, and realistically based on client capability. Outcomes should be derived from the diagnosis and should include a time estimate for attainment. Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, client, and significant others.

question

After a comprehensive assessment, correctly written nursing diagnoses developed for psychiatric clients may include which of the following components? (Select all that apply.) A. Medical judgments related to the psychiatric disorder B. Unmet client needs present at the moment C. Supporting data that validate the diagnosis D. Outcomes that will be targets for nursing interventions E. Statements of client problems of a functional nature

answer

ANS: B, C, E A nursing diagnosis is a statement of a client's functional problem. An actual nursing diagnosis must include related to (R/T) and as evidenced by (AEB) statements. A risk for diagnosis does not contain AEB because there is only a potential for the problem, it does not as yet exist.

question

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.) 1. Aversion therapy 2. Assertiveness training 3. Systematic desensitization 4. Benzodiazepine therapy 5. Imploding (flooding)

answer

3. Systematic desensitization 5. Imploding (flooding)

question

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) 1. Encourage the client to employ newly learned relaxation techniques. 2. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 3. Encourage the client to avoid any situation that causes stress. 4. Encourage the client to recognize the signs of escalating anxiety. 5. Encourage the client to avoid caffeinated products.

answer

1. Encourage the client to employ newly learned relaxation techniques. 2. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 4. Encourage the client to recognize the signs of escalating anxiety. 5. Encourage the client to avoid caffeinated products.

question

A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that learning has occurred? 1. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years. 2. Onset of symptoms most commonly occurs in early adolescence and persists until midlife. 3. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death. 4. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.

answer

1. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years.

question

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate? 1. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned. 2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD. 3. High doses of tricyclic medications will be required for effective treatment of OCD. 4. The dose of Luvox is low because of the side effect of daytime drowsiness.

answer

2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.

question

A client is experiencing a severe panic attack. Which nursing intervention would meet this client's physiological need? 1. Administer the ordered prn buspirone (BuSpar). 2. Have the client breathe into a paper bag. 3. Place the client in a Trendelenburg position. 4. Teach deep breathing relaxation exercises.

answer

2. Have the client breathe into a paper bag.

question

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? 1. "I won't stop taking this medication abruptly because there could be serious complications." 2. "I will not drink alcohol while taking this medication." 3. "I won't take extra doses of this drug because I can become addicted." 4. "I will need scheduled blood work in order to monitor for toxic levels of this drug."

answer

4. "I will need scheduled blood work in order to monitor for toxic levels of this drug."

question

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? 1. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." 2. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." 3. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks." 4. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."

answer

4. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."

question

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? 1. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors. 2. Distract the client with other activities whenever ritual behaviors begin. 3. Lock the room to discourage ritualistic behavior. 4. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.

answer

1. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

question

A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Order olanzapine (Zyprexa) to address altered thoughts. 3. Discontinue the fluoxetine and rethink the client's diagnosis. 4. Order benztropine (Cogentin) to address extrapyramidal symptoms.

answer

3. Discontinue the fluoxetine and rethink the client's diagnosis.

question

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Dysfunctional grieving R/T loss of employment 2. Imbalanced nutrition: less than body requirements R/T refusal to eat 3. Anxiety: severe R/T hyperactivity 4. Risk for suicide R/T hopelessness

answer

4. Risk for suicide R/T hopelessness

question

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately a month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "Weight gain only occurs during the first month of treatment with this drug." 2. "That's strange. Weight loss is the typical pattern." 3. "What have you been eating? Weight gain is not usually associated with lithium." 4. "Weight gain is a common, but troubling, side effect."

answer

4. "Weight gain is a common, but troubling, side effect."

question

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Monotherapy" tool 2. "Consensus Committee" tool 3. "FIND" tool 4. "Risky Activity" tool

answer

3. "FIND" tool

question

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

answer

4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

question

a

answer

c

question

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Trazodone (Desyrel) 2. Valproic acid (Depakote) 3. Paroxetine (Paxil) 4. Sertraline (Zoloft)

answer

2. Valproic acid (Depakote)

question

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa prevents extrapyramidal side effects." 2. "Zyprexa calms hyperactivity until the Eskalith takes effect." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa in combination with Eskalith cures manic symptoms."

answer

2. "Zyprexa calms hyperactivity until the Eskalith takes effect."

question

A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) . Numerous periods with manic symptoms 2. Possible comorbid diagnosis of a delusional disorder 3. Symptoms cause clinically significant impairment in important areas of functioning 4. Symptoms lasting for a minimum of two years 5. Depressive symptoms that do not meet the criteria for major depressive episode

answer

3. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode

question

Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 2. Genetic predisposition is not a reliable diagnostic determinant. 3. Neurotransmitter levels vary considerably in accordance with age. 4. Children are naturally active, energetic, and spontaneous. 5. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.

answer

4. Children are naturally active, energetic, and spontaneous. 5. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.

question

What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? 1. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. 2. GAD is acute in nature, and panic disorder is chronic. 3. Hyperventilation is a common symptom in GAD and rare in panic disorder. 4. Depersonalization is commonly seen in panic disorder and absent in GAD.

answer

4. Depersonalization is commonly seen in panic disorder and absent in GAD.

question

A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse's first priority? 1. Pain disorder and a nursing diagnosis of altered role performance 2. Panic disorder and a nursing diagnosis of anxiety 3. Altered sensory perception and a nursing diagnosis of panic disorder 4. Generalized anxiety disorder and a nursing diagnosis of fear

answer

2. Panic disorder and a nursing diagnosis of anxiety

question

Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

answer

2. Empowerment of the consumer

question

A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Initiate total parenteral nutrition to meet dietary needs. 2. Teach the importance of a varied diet to meet nutritional needs. 3. Provide client with high-calorie finger foods throughout the day. 4. Accompany client to cafeteria to encourage adequate dietary consumption.

answer

3. Provide client with high-calorie finger foods throughout the day.

question

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Agitated and pacing. Exhibiting grandiosity. Mood labile." 2. "Mood labile. Exhibiting delusions of reference. Hyperactive." 3. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 4. "Mood euthymic. Exhibiting magical thinking. Restless."

answer

1. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

question

A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania. 4. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.

answer

4. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.

question

Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

answer

2. Empowerment of the consumer

question

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Restrict sodium content. 2. Maintain a consistent sodium intake. 3. Avoid excessive use of beverages containing caffeine. 4. Restrict fluids to 1,500 mL per day. 5. Consume at least 2,500 to 3,000 mL of fluid per day.

answer

2. Maintain a consistent sodium intake. 3. Avoid excessive use of beverages 5. Consume at least 2,500 to 3,000 mL of fluid per day.

question

Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. Genetic predisposition is not a reliable diagnostic determinant. 2. Neurotransmitter levels vary considerably in accordance with age. 3. Children are naturally active, energetic, and spontaneous. 4. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 5. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.

answer

3. Children are naturally active, energetic, and spontaneous. 4. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.

question

What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? 1. GAD is acute in nature, and panic disorder is chronic. 2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. 3. Depersonalization is commonly seen in panic disorder and absent in GAD. 4. Hyperventilation is a common symptom in GAD and rare in panic disorder.

answer

3. Depersonalization is commonly seen in panic disorder and absent in GAD.

question

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? 1. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks." 2. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." 3. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." 4. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."

answer

4. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."

question

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.) 1. Benzodiazepine therapy 2. Aversion therapy 3. Assertiveness training 4. Systematic desensitization 5. Imploding (flooding)

answer

4. Systematic desensitization 5. Imploding (flooding)

question

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) 1. Encourage the client to avoid any situation that causes stress. 2. Encourage the client to employ newly learned relaxation techniques. 3. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 4. Encourage the client to avoid caffeinated products. 5. Encourage the client to recognize the signs of escalating anxiety.

answer

2. Encourage the client to employ newly learned relaxation techniques. 3. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 4. Encourage the client to avoid caffeinated products. 5. Encourage the client to recognize the signs of escalating anxiety.

question

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate? 1. The dose of Luvox is low because of the side effect of daytime drowsiness. 2. High doses of tricyclic medications will be required for effective treatment of OCD. 3. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned. 4. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.

answer

4. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.

question

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? 1. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors. 2. Distract the client with other activities whenever ritual behaviors begin. 3. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. 4. Lock the room to discourage ritualistic behavior.

answer

1. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

question

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing response? 1. "I know it's frightening, but try to remind yourself that this will only last a short time." 2. "Death from a panic attack happens so infrequently that there is no need to worry." 3. "Most people who experience panic attacks have feelings of impending doom." 4. "Tell me why you think you are going to die every time you have a panic attack."

answer

1. "I know it's frightening, but try to remind yourself that this will only last a short time."

question

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? 1. "I will not drink alcohol while taking this medication." 2. "I won't take extra doses of this drug because I can become addicted." 3. "I won't stop taking this medication abruptly because there could be serious complications." 4. "I will need scheduled blood work in order to monitor for toxic levels of this drug."

answer

4. "I will need scheduled blood work in order to monitor for toxic levels of this drug."

question

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? 1. History of personality disorder 2. History of alcohol use disorder 3. History of hypertension 4. History of schizophrenia

answer

2. History of alcohol use disorder

question

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? 1. The client will refrain from ritualistic behaviors during daylight hours. 2. The client will participate in three unit activities by day three. 3. The client will wake early enough to complete rituals prior to breakfast. 4. The client will substitute a productive activity for rituals by day one.

answer

3. The client will wake early enough to complete rituals prior to breakfast.

question

A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Dry mouth and urinary retention 4. Akinesia and insomnia

answer

1. Sore throat, fever, and malaise

question

An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 1. "Watch your diet and try to engage in some regular physical activity." 2. "Make sure you concentrate on taking slow, deep, cleansing breaths." 3. "Wear sunscreen and try to avoid midday sun exposure." 4. "Rise slowly when you change position from lying to sitting or sitting to standing."

answer

4. "Rise slowly when you change position from lying to sitting or sitting to standing."

question

A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?

answer

1. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.

question

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?

answer

1. "Treatment is compromised when clients choose not to take their medications."

question

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior?

answer

3. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

question

a

answer

aa

question

A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.)

answer

Correct1. Depressive symptoms that do not meet the criteria for major depressive episode Correct5. Symptoms cause clinically significant impairment in important areas of functioning

question

a

answer

a

question

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.)

answer

1. Encourage the client to employ newly learned relaxation techniques. 2. Encourage the client to recognize the signs of escalating anxiety. 3. Encourage the client to avoid caffeinated products. 5. Encourage the client to cognitively reframe thoughts about situations that generate anxiety

question

An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.)

answer

Correct2. Mirror checking Correct3. Excessive grooming Correct4. Skin picking

question

A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that learning has occurred? 1. "These clients have a panic level of fear that is overwhelming and unreasonable." 2. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis." 3. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." 4. "These clients recognize their fear as excessive and frequently seek treatment."

answer

Correct1. "These clients have a panic level of fear that is overwhelming and unreasonable."

question

A

answer

C

question

A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) a mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

answer

Correct1. Restlessness and muscle rigidity

question

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate the development of lithium carbonate tolerance. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate consumption of foods high in tyramine. 4. Symptoms indicate lithium carbonate toxicity.

answer

4. Symptoms indicate lithium carbonate toxicity.

question

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Trazodone (Desyrel) 2. Valproic acid (Depakote) 3. Sertraline (Zoloft) 4. Paroxetine (Paxil)

answer

2. Valproic acid (Depakote)

question

Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Improved psychosocial relationships 3. Total absence of symptoms 4. Empowerment of the consumer

answer

4. Empowerment of the consumer

question

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa increases the effectiveness of the immune system." 2. "Zyprexa calms hyperactivity until the Eskalith takes effect." 3. "Zyprexa in combination with Eskalith cures manic symptoms." 4. "Zyprexa prevents extrapyramidal side effects."

answer

2. "Zyprexa calms hyperactivity until the Eskalith takes effect."

question

A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Order benztropine (Cogentin) to address extrapyramidal symptoms. 2. Order olanzapine (Zyprexa) to address altered thoughts. 3. Discontinue the fluoxetine and rethink the client's diagnosis. 4. Increase the dosage of fluoxetine.

answer

3. Discontinue the fluoxetine and rethink the client's diagnosis.

question

A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.) 1. Fatigue 2. Irritability 3. Hyperventilation 4. Insomnia 5. Anorexia

answer

1. Fatigue 2. Irritability 4. Insomnia

question

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? 1. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks." 2. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." 3. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." 4. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder."

answer

3. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."

question

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? 1. Intellectualization 2. Sublimation 3. Rationalization 4. Dissociation

answer

1. Intellectualization

question

A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse's first priority? 1. Altered sensory perception and a nursing diagnosis of panic disorder 2. Panic disorder and a nursing diagnosis of anxiety 3. Generalized anxiety disorder and a nursing diagnosis of fear 4. Pain disorder and a nursing diagnosis of altered role performance

answer

2. Panic disorder and a nursing diagnosis of anxiety

question

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? 1. Distract the client with other activities whenever ritual behaviors begin. 2. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors. 3. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. 4. Lock the room to discourage ritualistic behavior.

answer

2. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

question

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Maintain a consistent sodium intake. 2. Restrict sodium content. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Avoid excessive use of beverages containing caffeine. 5. Restrict fluids to 1,500 mL per day.

answer

1. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Avoid excessive use of beverages containing caffeine.

question

A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) a mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? 1. Tactile hallucinations 2. Tardive dyskinesia 3. Restlessness and muscle rigidity 4. Reports of hearing disturbing voices

answer

3. Restlessness and muscle rigidity

question

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would a nurse expect to observe during assessment? (Select all that apply.) 1. Apathy 2. Anhedonia 3. Delusions 4. Social withdrawal 5. Auditory hallucinations

answer

1. Apathy 2. Anhedonia 4. Social withdrawal

question

Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder? 1. Provide neon lights and soft music. 2. Maintain continual eye contact throughout the interview. 3. Use therapeutic touch to increase trust and rapport. 4. Provide personal space to respect the client's boundaries.

answer

4. Provide personal space to respect the client's boundaries.

question

After taking chlorpromazine (Thorazine) for a month, a client presents to an ED with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5°C). Which medical diagnosis and treatment should a nurse anticipate whεn planning care for this client? 1. Dystonia treated by administering bromocriptine (Parlodel) 2. Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication 3. Dystonia treated by administering trihexyphenidyl (Artane) 4. Neuroleptic malignant syndrome treated by discontinuing

answer

4. Neuroleptic malignant syndrome treated by discontinuing

question

A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? 1. Persecutory delusions; orient the client to reality. 2. Altered thought processes; call an emergency treatment team meeting. 3. Magical thinking; administer an antipsychotic medication. 4. Command hallucinations; warn the psychiatrist.

answer

4. Command hallucinations; warn the psychiatrist.

question

A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client? 1. Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications 2. Tardive dyskinesia treated by discontinuing antipsychotic medications 3. Extrapyramidal symptoms treated by administration of benztropine (Cogentin) 4. Agranulocytosis treated by administration of clozapine (Clozaril)

answer

2. Tardive dyskinesia treated by discontinuing antipsychotic medications

question

A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1. Magical thinking 2. Paranoid delusions 3. Thought insertion 4. Delusions of reference

answer

4. Delusions of reference

question

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? 1. Assess for medication nonadherance. 2. Assess triggers for bizarre, inappropriate behaviors. 3. Note escalating behaviors and intervene immediately. 4. Interpret attempts at communication.

answer

3. Note escalating behaviors and intervene immediately.

question

A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize? 1. Weight gain of 8 pounds in 2 months 2. Temperature of 104°F (40°C) 3. Excessive salivation 4. Respirations of 22 beats/minute

answer

2. Temperature of 104°F (40°C)

question

The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.) 1. Hyperaphia 2. Hypothyroidism 3. Hypoadrenalism 4. Hyperadrenalism 5. Hyperthyroidism

answer

2. Hypothyroidism 3. Hypoadrenalism 4. Hyperadrenalism 5. Hyperthyroidism

question

A client diagnosed with schizopηrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client? 1. Altered thought processes 2. Risk for violence: directed toward others 3. Disturbed sensory perception 4. Risk for injury

answer

2. Risk for violence: directed toward others

question

Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder? 1. Maintain continual eye contact throughout the interview. 2. Provide personal space to respect the client's boundaries. 3. Use therapeutic touch to increase trust and rapport. 4. Provide neon lights and soft music.

answer

2. Provide personal space to respect the client's boundaries.

question

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client? 1. Risk for injury 2. Risk for violence: directed toward others 3. Disturbed sensory perception 4. Altered thought processes

answer

2. Risk for violence: directed toward others

question

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? 1. Note escalating behaviors and intervene immediately. 2. Assess triggers for bizarre, inappropriate behaviors. 3. Assess for medication nonadherance. 4. Interpret attempts at communication.

answer

1. Note escalating behaviors and intervene immediately.

question

A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? 1. Magical thinking; administer an antipsychotic medication. 2. Altered thought processes; call an emergency treatment team meeting. 3. Persecutory delusions; orient the client to reality. 4. Command hallucinations; warn the psychiatrist.

answer

4. Command hallucinations; warn the psychiatrist.

question

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia. 2. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 3. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 4. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.

answer

3. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.

question

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1. Sharing limited personal information 2. Being reliable, honest, and consistent during interactions 3. Sitting close to the client to establish rapport 4. Establishing personal contact with family members

answer

2. Being reliable, honest, and consistent during interactions

question

An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Which group is this nurse most qualified to lead? 1. A family therapy group 2. A psychotherapy group 3. A psychodrama group 4. A parenting group

answer

4. A parenting group

question

Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) 1. "Let's focus on the current problem." 2. "Tell me what happened." 3. "Describe to me what your life was like before this happened." 4. "I'll assist you in selecting functional coping strategies." 5. "What coping methods have you used, and did they work?"

answer

Correct2. "Tell me what happened." Correct3. "Describe to me what your life was like before this happened." Correct5. "What coping methods have you used, and did they work?"

question

Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? (Select all that apply.) 1. Help the leader to resolve conflicts and foster cohesiveness within the group. 2. Emphasize the need for and importance of confidentiality within the group. 3. Ensure that group rules do not interfere with goal fulfillment. 4. Work with group members to establish rules that will govern the group. 5. Encourage members to provide feedback to each other about individual progress.

answer

Correct2. Emphasize the need for and importance of confidentiality within the group. Correct3. Ensure that group rules do not interfere with goal fulfillment. Correct4. Work with group members to establish rules that will govern the group.

question

After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? 1. "Why do you want to harm yourself?" 2. "Have you thought about the consequences of your actions?" 3. "Are you currently thinking about harming yourself?" 4. "Who is your emergency contact person?"

answer

Correct3. "Are you currently thinking about harming yourself?"

question

An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation? 1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within a hour of the initiation of the restraints. 2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within b hours of the initiation of the restraints. 3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within d hours of the initiation of the restraints. 4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within c hours of the initiation of the restraints.

answer

1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within a hour of the initiation of the restraints.

question

A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis? Answers: 1. This type of crisis is precipitated by unexpected external stressors. 2. This type of crisis is precipitated by preexisting psychopathology. 3. This type of crisis is precipitated by an acute response to an external situational stressor. 4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

answer

4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

question

During a community meeting, a nurse encourages clients to present unit problems and discuss possible solutions. Which type of leadership style is the nurse demonstrating? Answers: 1. Laissez-faire 2. Bureaucratic 3. Autocratic 4. Democratic

answer

4. Democratic

question

During an inpatient educational group, a client shouts out, "This information is worthless. Nothing you have said can help me." These statements indicate to a nurse leader that the client is assuming which group role? Answers: 1. The group role of initiator 2. The group role of aggressor 3. The group role of blocker 4. The group role of gatekeeper

answer

2. The group role of aggressor

question

During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style? 1. The nurse asks for a show of hands to determine group topic preference. 2. The nurse mandates that all group members reveal an embarrassing personal situation. 3. The nurse shuffles through papers to determine the facility policy on length of group. 4. The nurse sits silently as the group members stray from the assigned topic.

answer

4. The nurse sits silently as the group members stray from the assigned topic.

question

Which situation should a nurse identify as an example of an autocratic leadership style? Answers: 1. During a community meeting, a nurse listens as clients generate solutions. 2. The student nurses' association advertises for candidates for president. 3. Without faculty input, the dean mandates that all course content be delivered via the Internet. 4. The president of Sigma Theta Tau assigns members to committees to research problems.

answer

3. Without faculty input, the dean mandates that all course content be delivered via the Internet.

question

An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Which group is this nurse most qualified to lead? Answers: 1. A family therapy group 2. A psychotherapy group 3. A psychodrama group 4. A parenting group

answer

4. A parenting group

question

A client with chronic lower back pain says, "My nurse practitioner told me that acupuncture may enhance the effect of the medications and physical therapy prescribed." What type of therapy is the nurse practitioner recommending? 1. Alternative therapy 2. Physiotherapy 3. Biopsychosocial therapy 4. Complementary therapy

answer

4. Complementary therapy

question

A client inquires about the practice of therapeutic touch. Which nursing response best explains the goal of this therapy? 1. "The goal is to improve breathing by increasing oxygen to the brain and body tissues." 2. "The goal is to re-pattern the body's energy field by the use of rhythmic hand motions." 3. "The goal is to improve circulation to the body by deep, circular massage." 4. "The goal is to decrease blood pressure by body toxin release."

answer

2. "The goal is to re-pattern the body's energy field by the use of rhythmic hand motions."

question

A client diagnosed with chronic migraine headaches is considering acupuncture. The client asks a clinic nurse, "How does this treatment work?" Which is the best response by the nurse? 1. "Your acupuncturist is your best resource for answering your specific questions." 2. "Western medicine believes that acupuncture stimulates the body's release of pain-fighting chemicals called endorphins." 3. "I'm not sure why he suggested acupuncture. There are a lot of risks, including HIV." 4. "Acupuncture works by encouraging the body to increase its development of serotonin and norepinephrine."

answer

2. "Western medicine believes that acupuncture stimulates the body's release of pain-fighting chemicals called endorphins."

question

A client reports taking St. John's wort for major depressive episode. The client states, "I'm taking the recommended dose, but it seems like if two capsules are good, four would be better!" Which is an appropriate nursing response? Answers: 1. "Increasing the amount of herbal preparations can lead to overdose and toxicity." 2. "FDA does not regulate herbal remedies, therefore, ingredients are often unknown." 3. "Certain companies are better than others. Always buy a reputable brand." 4. "Herbal medicines are more likely to cause adverse reactions than prescription medications."

answer

1. "Increasing the amount of herbal preparations can lead to overdose and toxicity."

question

A lethargic client is diagnosed with major depressive disorder. After taking antidepressant therapy for 6 weeks, the client's symptoms have not resolved. Which nutritional deficiency should a nurse identify as potentially contributing to the client's symptoms? Answers: 1. Vitamin A deficiency 2. Vitamin C deficiency 3. Folic acid deficiency 4. Iron deficiency

answer

4. Iron deficiency

question

A nursing instructor is teaching about complementary therapies. Which student statement indicates that learning has occurred? 1. "Complementary therapies view a person as a combination of multiple, integrated elements." 2. "Complementary therapies view disease as a deviation from a normal biological state." 3. "Complementary therapies focus on primarily the structure and functions of the body." 4. "Complementary therapies view all humans as being biologically similar."

answer

1. "Complementary therapies view a person as a combination of multiple, integrated elements."

question

A nurse teaches a client about alternative therapies for back pain. When a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, what therapy is the practitioner employing? 1. Chiropractic therapy 2. Massage therapy 3. Allopathic therapy 4. Therapeutic touch therapy

answer

1. Chiropractic therapy

question

Alternative approaches refer to interventions that are used instead of conventional treatment. A client asks a nurse to explain the difference between alternative and complementary medicine. Which is an appropriate nursing response? Answers: 1. "Complementary medicine disregards traditional medical approaches." 2. "Alternative and complementary medicine are terms that essentially mean the same thing." 3. "Complementary therapies partner alternative approaches with traditional medical practice." 4. "Alternative medicine is a more acceptable practice than complementary medicine." Response Feedback:

answer

3. "Complementary therapies partner alternative approaches with traditional medical practice."

question

Which of the following practices should a nurse describe to a client as being incorporated during yoga therapy? (Select all that apply.) Answers: 1. Meridian therapy 2. Deep breathing 3. Balanced body postures 4. Massage therapy 5. Meditation

answer

Correct2. Deep breathing Correct3. Balanced body postures Correct5. Meditation

question

A client who prefers to use St. John's wort and psychotherapy in lieu of antidepressant therapy asks for tips on using herbal remedies. Which of the following teaching points should a nurse provide? (Select all that apply.) Answers: 1. Gradually increase dosage to gain maximum effect. 2. Most herbal remedies are best absorbed on an empty stomach. 3. Monitor for adverse reactions. 4. Increasing dosage does not lead to improved effectiveness. 5. Select a reputable brand.

answer

Correct3. Monitor for adverse reactions. Correct4. Increasing dosage does not lead to improved effectiveness. Correct5. Select a reputable brand.

question

A nurse is assessing a pathological gambler. What would differentiate this client's behaviors from the behaviors of a non-pathological gambler? Answers: 1. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course. 2. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men. 3. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not. 4. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief.

answer

3. Pathological gamblers have abnormal levels of neurotransmitters, whereas non-pathological gamblers do not.

question

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance addiction? Answers: 1. There is no need to assess the client for substance addiction. There is an obvious PCA malfunction, because these clients have a higher pain tolerance. 2. The client is experiencing alcohol withdrawal symptoms and needs accurate assessment. 3. Narcotic pain medication is contraindicated for all clients with active substance use disorders. 4. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control.

answer

4. Clients who are addicted to alcohol or benzodiazepines may develop cross-tolerance to analgesics and require increased doses to achieve effective pain control.

question

A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? Answers: 1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. 2. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. 3. Sedative-hypnotics are expensive and have numerous side effects. 4. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications.

answer

1. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance.

question

A client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? Answers: 1. Knowledge deficit 2. Imbalanced nutrition: less than body requirements 3. Ineffective individual coping 4. Fluid volume excess

answer

2. Imbalanced nutrition: less than body requirements

question

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? Answers: 1. To assess for emotional strength 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for tachycardia 4. To assess for fine tremors

answer

4. To assess for fine tremors

question

Which client statement indicates a knowledge deficit related to a substance use disorder? Answers: 1. "Tolerance to heroin develops quickly." 2. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless." 3. "Flashbacks from LSD use may reoccur spontaneously." 4. "Although it's legal, alcohol is one of the most widely abused drugs in our society."

answer

2. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

question

Which client statement demonstrates positive progress toward recovery from a substance use disorder? Answers: 1. "I have completed detox and therefore am in control of my drug use." 2. "Taking those pills got out of control. It cost me my job, marriage, and children." 3. "As a church deacon, my focus will now be on spiritual renewal." 4. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my cravings."

answer

2. "Taking those pills got out of control. It cost me my job, marriage, and children."

question

A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? Answers: 1. Physical addiction 2. Social induced disorder 3. Psychological addiction 4. Substance induced disorder

answer

3. Psychological addiction

question

A nursing supervisor is offering an impaired staff member information regarding employee assistance programs. Which of the following facts should the supervisor include? (Select all that apply.) Answers: 1. Contact to provide peer support will last for one year. 2. One of the program goals is to intervene early in order to reduce hazards to clients. 3. A verbal contract detailing the method of treatment will be initiated prior to the program. 4. Peer support is provided through regular contact with the impaired nurse. 5. A hotline number will be available in order to call for peer assistance.

answer

2. One of the program goals is to intervene early in order to reduce hazards to clients. Correct4. Peer support is provided through regular contact with the impaired nurse. Correct5. A hotline number will be available in order to call for peer assistance.

question

A clinic nurse is about to meet with a client diagnosed with a gambling disorder. Which of the following symptoms and/or behaviors is the nurse likely to assess? (Select all that apply.) Answers: 1. Winning brings about feelings of sexual satisfaction. 2. Anxiety and restlessness can only be relieved by placing a bet. 3. Stressful situations precipitate gambling behaviors. 4. Losing at gambling meets the client's need for self-punishment. 5. Gambling is used as a coping strategy.

answer

Correct2. Anxiety and restlessness can only be relieved by placing a bet. Correct3. Stressful situations precipitate gambling behaviors. Correct4. Losing at gambling meets the client's need for self-punishment. Correct5. Gambling is used as a coping strategy.

question

After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem? 1. "Are you consuming foods high in tyramine?" 2. "Do you drink any alcohol?" 3. "How many packs of cigarettes do you smoke daily?" 4. "Are you taking St. John's wort?"

answer

3.. "How many packs of cigarettes do you smoke daily?"

question

A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? Answers: 1. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation. 2. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles. 3. To prevent blocked airway, resulting from seizure activity. 4. To prevent increased intracranial pressure resulting from anoxia.

answer

Correct2. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles.

question

The nurse administers 100% oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles. Answers: 1. Give the client off-unit privileges as positive reinforcement. 2. Request that the psychiatrist reevaluate the current medication protocol. 3. Increase the level of this client's suicide precautions. 4. Encourage the client to share mood improvement in group.

answer

Correct3. Increase the level of this client's suicide precautions.

question

A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis? Answers: 1. Potassium (K+) level of 4.2 mEq/L 2. Calcium (Cab+) level of 9.5 mg/dL 3. Sodium (Na+) level of 140 mEq/L 4. Thyroid-stimulating hormone (TSH) level of 25 U/mL

answer

Correct4. Thyroid-stimulating hormone (TSH) level of 25 U/mL

question

An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why? Answers: 1. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI 2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) 3. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) 4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

answer

4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

question

The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms? Answers: 1. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions) 2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 3. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations) 4. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia)

answer

2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)

question

In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? Answers: 1. The client will establish a trusting relationship with the nurse. 2. The client will express hope for the future by day three. 3. The client will remain safe during hospital stay. 4. The client will not physically harm self.

answer

3. The client will remain safe during hospital stay.

question

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? Answers: 1. Altered communication R/T feelings of worthlessness AEB anhedonia 2. Social isolation R/T poor self-esteem AEB secluding self in room 3. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia 4. Altered thought processes R/T hopelessness AEB persecutory delusions

answer

2. Social isolation R/T poor self-esteem AEB secluding self in room

question

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) Answers: 1. Labile mood 2. Sad mood on most days 3. Sad mood for the past 3 years after spouse's death 4. Mood rating of 2 out of 10 for the past 6 months 5. Pressured speech when communicating

answer

Correct2. Sad mood on most days Correct3. Sad mood for the past 3 years after spouse's death

question

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) Answers: 1. Inaccessibility of resources for dealing with life stressors 2. Variations in serotonergic functioning 3. Gender differences in social opportunities that occur with age 4. A seasonal increase in social interactions 5. Drastic temperature and barometric pressure changes

answer

2. Variations in serotonergic functioning Correct4. A seasonal increase in social interactions Correct5. Drastic temperature and barometric pressure changes

question

When planning group therapy, a nurse should identify which configuration as most optimal for a therapeutic group? Answers: 1. Open-ended membership; chairs around a table; group size of 10 to 15 members 2. Closed membership; chairs around a table; group size of 10 to 15 members 3. Open-ended membership; circle of chairs; group size of 5 to 10 members 4. Closed membership; circle of chairs; group size of 5 to 10 members

answer

4. Closed membership; circle of chairs; group size of 5 to 10 members

question

Which situation should a nurse identify as an example of an autocratic leadership style? Answers: 1. During a community meeting, a nurse listens as clients generate solutions. 2. The student nurses' association advertises for candidates for president. 3. The president of Sigma Theta Tau assigns members to committees to research problems. 4. Without faculty input, the dean mandates that all course content be delivered via the Internet

answer

4. Without faculty input, the dean mandates that all course content be delivered via the Internet

question

An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression? Answers: 1. The client requests prn medications. 2. The client has a tense facial expression and body language. 3. The client sits in group with back to peers. 4. The client refuses to eat lunch.

answer

2. The client has a tense facial expression and body language.

question

An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation? Answers: 1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within b hours of the initiation of the restraints. 2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within c hours of the initiation of the restraints. 3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within d hours of the initiation of the restraints. 4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within a hour of the initiation of the restraints.

answer

4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within a hour of the initiation of the restraints.

question

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client? Answers: 1. Risk for low self-esteem R/T loss events AEB suicidal ideations 2. Risk for self-directed violence R/T hopelessness 3. Anxiety R/T fear of failure 4. Ineffective coping R/T situational crisis AEB powerlessness

answer

2. Risk for self-directed violence R/T hopelessness

question

Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) Answers: 1. "Let's focus on the current problem." 2. "Describe to me what your life was like before this happened." 3. "I'll assist you in selecting functional coping strategies." 4. "Tell me what happened." 5. "What coping methods have you used, and did they work?"

answer

2. "Describe to me what your life was like before this happened." 4. "Tell me what happened." 5. "What coping methods have you used, and did they work?"

question

A nursing instructor is teaching students about self-help groups like Alcoholics Anonymous (AA). Which student statement indicates that learning has occurred? Answers: 1. "These groups have no external regulation, so clients need to be cautious." 2. "There is little research to support AA's effectiveness." 3. "Members themselves run the group, with leadership usually rotating among the members." 4. "Self-help groups used to be the treatment of choice, but their popularity is waning."

answer

3. "Members themselves run the group, with leadership usually rotating among the members."

question

Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development? Answers: 1. The group leader helps the members to process feelings of loss. 2. The group leader establishes the rules that will govern the group after discharge. 3. The group leader presents and discusses the concept of group termination. 4. The group leader encourages members to rely on each other for problem solving.

answer

1. The group leader helps the members to process feelings of loss.

question

During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style? Answers: 1. The nurse sits silently as the group members stray from the assigned topic. 2. The nurse mandates that all group members reveal an embarrassing personal situation. 3. The nurse asks for a show of hands to determine group topic preference. 4. The nurse shuffles through papers to determine the facility policy on length of group.

answer

1. The nurse sits silently as the group members stray from the assigned topic.

question

A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step? Answers: 1. Step 6: Following client-designed plan, caregivers now become decision-makers. 2. Step 5: A specific plan to help with symptoms is formulated. 3. Step 4: Signs indicating relapse are identified and plans for responding are developed. 4. Step 3: Triggers that cause distress or discomfort are listed.

answer

1. Step 6: Following client-designed plan, caregivers now become decision-makers.

question

A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to fine when assessing this client? Answers: 1. A client feeling confident about achieving goals in life. 2. A client who is aware of the need to set goals in life. 3. A client who has mobilized personal and external resources. 4. A client who begins to actively take control of his or her life

answer

1. A client feeling confident about achieving goals in life.

question

A lethargic client is diagnosed with major depressive disorder. After taking antidepressant therapy for 6 weeks, the client's symptoms have not resolved. Which nutritional deficiency should a nurse identify as potentially contributing to the client's symptoms? Answers: 1. Vitamin A deficiency 2. Iron deficiency 3. Vitamin C deficiency 4. Folic acid deficiency

answer

2. Iron deficiency

question

A client inquires about pet therapy. Which of the following nursing responses provides the client with accurate information? (Select all that apply.) Answers: 1. "Pet therapy enhances client mood." 2. "Pet therapy mitigates the effects of loneliness." 3. "Pet therapy allows the therapist to assess the client's social relationships." 4. "Pet therapy improves sensory functioning." 5. "Pet therapy decreases blood pressure."

answer

1. "Pet therapy enhances client mood." 2. "Pet therapy mitigates the effects of loneliness." 5. "Pet therapy decreases blood pressure."

question

A client with chronic lower back pain says, "My nurse practitioner told me that acupuncture may enhance the effect of the medications and physical therapy prescribed." What type of therapy is the nurse practitioner recommending? Answers: 1. Alternative therapy 2. Complementary therapy 3. Physiotherapy 4. Biopsychosocial therapy

answer

2. Complementary therapy

question

A nursing student, having no knowledge of alternative treatments, states, "Aren't these therapies 'bogus' and, like a fad, will eventually fade away?" Which is an accurate nursing response? Answers: 1. "The American Nurses Association is researching the effectiveness of these therapies." 2. "It is important to remain nonjudgmental about these therapies." 3. "Like nursing, complementary therapies take a holistic approach to healing." 4. "Alternative therapy concepts are rooted in psychoanalysis

answer

3. "Like nursing, complementary therapies take a holistic approach to healing."

question

Herbs and plants can be useful in treating a variety of conditions. Which treatment should a nurse determine is appropriate for a client experiencing frequent migraine headaches? Answers: 1. Ginger root combined with a beta-blocker 2. Saint John's wort combined with an antidepressant 3. Kava-kava added to a regular diet 4. Feverfew, used according to directions

answer

4. Feverfew, used according to directions

question

A nursing instructor is teaching about complementary therapies. Which student statement indicates that learning has occurred? Answers: 1. "Complementary therapies focus on primarily the structure and functions of the body." 2. "Complementary therapies view disease as a deviation from a normal biological state." 3. "Complementary therapies view a person as a combination of multiple, integrated elements." 4. "Complementary therapies view all humans as being biologically similar."

answer

3. "Complementary therapies view a person as a combination of multiple, integrated elements."

question

A client diagnosed with chronic migraine headaches is considering acupuncture. The client asks a clinic nurse, "How does this treatment work?" Which is the best response by the nurse? Answers: 1. "Acupuncture works by encouraging the body to increase its development of serotonin and norepinephrine." 2. "Your acupuncturist is your best resource for answering your specific questions." 3. "Western medicine believes that acupuncture stimulates the body's release of pain-fighting chemicals called endorphins." 4. "I'm not sure why he suggested acupuncture. There are a lot of risks, including HIV."

answer

3. "Western medicine believes that acupuncture stimulates the body's release of pain-fighting chemicals called endorphins."

question

A client inquires about the practice of therapeutic touch. Which nursing response best explains the goal of this therapy? Answers: 1. "The goal is to improve circulation to the body by deep, circular massage." 2. "The goal is to re-pattern the body's energy field by the use of rhythmic hand motions." 3. "The goal is to improve breathing by increasing oxygen to the brain and body tissues." 4. "The goal is to decrease blood pressure by body toxin release.

answer

2. "The goal is to re-pattern the body's energy field by the use of rhythmic hand motions."

question

Alternative approaches refer to interventions that are used instead of conventional treatment. A client asks a nurse to explain the difference between alternative and complementary medicine. Which is an appropriate nursing response? Answers: 1. "Complementary therapies partner alternative approaches with traditional medical practice." 2. "Complementary medicine disregards traditional medical approaches." 3. "Alternative medicine is a more acceptable practice than complementary medicine." 4. "Alternative and complementary medicine are terms that essentially mean the same thing."

answer

1. "Complementary therapies partner alternative approaches with traditional medical practice."

question

Which of the following statements reflect current attitudes toward complementary and alternative therapies? (Select all that apply.) Answers: 1. A large number of U.S. medical schools, among them Harvard and Yale, now offer coursework in holistic methods 2. The majority of third-party payers do not cover chiropractic client treatments. 3. The AMA encourages members to be better informed regarding alternative medicine. 4. Some health insurance companies are beginning to cover treatments such as acupuncture and massage therapy. 5. Interest in holistic health care is decreasing worldwide.

answer

1. A large number of U.S. medical schools, among them Harvard and Yale, now offer coursework in holistic methods 3. The AMA encourages members to be better informed regarding alternative medicine. 4. Some health insurance companies are beginning to cover treatments such as acupuncture and massage therapy.

question

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? Answers: 1. Ineffective coping R/T powerlessness over alcohol use 2. Risk for injury R/T central nervous system stimulation 3. Ineffective denial R/T continued alcohol use despite negative consequences 4. Disturbed thought processes R/T tactile hallucinations

answer

2. Risk for injury R/T central nervous system stimulation

question

A client diagnosed with a gambling disorder asks the nurse about medications that may be ordered by the client's physician to treat this disorder. The nurse would give the client information on which medications? Answers: 1. Lithium carbonate (Lithobid) and sertraline (Zoloft) 2. Citalopram (Celexa) and olanzapine (Zyprexa) 3. Escitalopram (Lexapro) and clozapine (Clozaril) 4. Naltrexone (ReVia) and ziprasidone (Geodon)

answer

1. Lithium carbonate (Lithobid) and sertraline (Zoloft)

question

A nurse is assessing a pathological gambler. What would differentiate this client's behaviors from the behaviors of a non-pathological gambler? Answers: 1. Pathological gambling occurs more commonly among women, whereas non-pathological gambling occurs more commonly among men. 2. Pathological gambling is not related to stress relief, whereas non-pathological gambling is related to stress relief. 3. Pathological gambling generally runs an acute course, whereas non-pathological gambling runs a chronic course. 4. Pathological gamblers have abnormal levels of neurotransmitters, whereas

answer

4. Pathological gamblers have abnormal levels of neurotransmitters, whereas

question

Which medication orders should a nurse anticipate for a client who has a history of benzodiazepine withdrawal delirium? Answers: 1. Haloperidol (Haldol) and fluoxetine (Prozac) 2. Disulfiram (Antabuse) and lorazepan (Ativan) 3. Carbamazepine (Tegretol) and donepezil (Aricept) 4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

answer

4. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

question

Which client statement demonstrates positive progress toward recovery from a substance use disorder? Answers: 1. "Taking those pills got out of control. It cost me my job, marriage, and children." 2. "I have completed detox and therefore am in control of my drug use." 3. "As a church deacon, my focus will now be on spiritual renewal." 4. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my cravings."

answer

1. "Taking those pills got out of control. It cost me my job, marriage, and children."

question

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? Answers: 1. To assess for tachycardia 2. To assess for Wernicke-Korsakoff syndrome 3. To assess for fine tremors 4. To assess for emotional strength

answer

3. To assess for fine tremors

question

A client diagnosed with major depressive episode and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? compromised owing to tolerance. Answers: 1. Sedative-hypnotics are expensive and have numerous side effects. 2. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance. 3. Sedative-hypnotics are known not to be as effective in promoting sleep as antidepressant medications. 4. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.

answer

2. Sedative-hypnotics are potentially addictive, and their effectiveness will be compromised owing to tolerance.

question

A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? Answers: 1. Social induced disorder 2. Substance induced disorder 3. Psychological addiction 4. Physical addiction

answer

3. Psychological addiction

question

A client presents with symptoms of alcohol withdrawal and states, "I haven't eaten in three days." A nurse's assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry mucous membranes and poor skin turgor. What should be the priority nursing diagnosis? Answers: 1. Ineffective individual coping 2. Knowledge deficit 3. Fluid volume excess 4. Imbalanced nutrition: less than body requirements

answer

4. Imbalanced nutrition: less than body requirements

question

A nursing instructor is teaching nursing students about cirrhosis of the liver. Which of the following statements about the complications of hepatic encephalopathy should indicate to the nursing instructor that further student teaching is needed? (Select all that apply.) Answers: 1. "This condition results from a rise in serum ammonia, leading to impaired mental functioning." 2. "Neomycin and lactulose are used in the treatment of this condition." 3. "A diet rich in protein will promote hepatic healing." 4. "In this condition, an excessive amount of serous fluid accumulates in the abdominal cavity." 5. "This condition is caused by the inability of the liver to convert ammonia to urea."

answer

3. "A diet rich in protein will promote hepatic healing."

question

A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.) Answers: 1. The client is a people pleaser and does almost anything to gain approval. 2. The client exhibits helpless behaviors but actually feels very competent. 3. The client, as a child, experienced overindulgent and overprotective parents. 4. The client can achieve a sense of control only through fulfilling the needs of others. 5. The client has a long history of focusing thoughts and behaviors on other people.

answer

1. The client is a people pleaser and does almost anything to gain approval. 4. The client can achieve a sense of control only through fulfilling the needs of others. 5. The client has a long history of focusing thoughts and behaviors on other people.

question

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client's safety upon discharge? Answers: 1. Provide education regarding the avoidance of foods containing tyramine. 2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments. 3. Provide a 6-month supply of Elavil to ensure long-term compliance. 4. Provide pill dispenser as a memory aid.

answer

2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments.

question

An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why? Answers: 1. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI 2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) 3. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) 4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

answer

4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs

question

A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse's priority at this time? Answers: 1. Increase the level of this client's suicide precautions. 2. Give the client off-unit privileges as positive reinforcement. 3. Encourage the client to share mood improvement in group. 4. Request that the psychiatrist reevaluate the current medication protocol.

answer

1. Increase the level of this client's suicide precautions.

question

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response? Answers: 1. "This combination of drugs can lead to delirium tremens." 2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." 3. "The only disadvantage would be the exorbitant cost of the MAOI." 4. "That's a good idea. There have been good results with the combination of these two drugs."

answer

2. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis."

question

In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? Answers: 1. The client will express hope for the future by day three. 2. The client will remain safe during hospital stay. 3. The client will not physically harm self. 4. The client will establish a trusting relationship with the nurse.

answer

2. The client will remain safe during hospital stay.

question

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? Answers: 1. Social isolation R/T poor self-esteem AEB secluding self in room 2. Altered communication R/T feelings of worthlessness AEB anhedonia 3. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia 4. Altered thought processes R/T hopelessness AEB persecutory delusions

answer

1. Social isolation R/T poor self-esteem AEB secluding self in room

question

A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure? 1. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles. 2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation. 3. To prevent increased intracranial pressure resulting from anoxia. 4. To prevent blocked airway, resulting from seizure activity.

answer

1. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles.

question

The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms? Answers: 1. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations) 2. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia) 3. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby) 4. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions)

answer

3. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)

question

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) Answers: 1. Pressured speech when communicating 2. Sad mood for the past 3 years after spouse's death 3. Sad mood on most days 4. Labile mood 5. Mood rating of 2 out of 10 for the past 6 months

answer

2. Sad mood for the past 3 years after spouse's death 3. Sad mood on most days

question

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) Answers: 1. Gender differences in social opportunities that occur with age 2. Drastic temperature and barometric pressure changes 3. Variations in serotonergic functioning 4. Inaccessibility of resources for dealing with life stressors 5. A seasonal increase in social interactions

answer

2. Drastic temperature and barometric pressure changes 3. Variations in serotonergic functioning 5. A seasonal increase in social interactions

question

A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) Answers: 1. Sad mood for the past 3 years after spouse's death 2. Labile mood 3. Mood rating of 2 out of 10 for the past 6 months 4. Sad mood on most days 5. Pressured speech when communicating

answer

1. Sad mood for the past 3 years after spouse's death 4. Sad mood on most days

question

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder? Answers: 1. Altered thought processes R/T hopelessness AEB persecutory delusions 2. Altered communication R/T feelings of worthlessness AEB anhedonia 3. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia 4. Social isolation R/T poor self-esteem AEB secluding self in room

answer

4. Social isolation R/T poor self-esteem AEB secluding self in room

question

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response? Answers: 1. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." 2. "This combination of drugs can lead to delirium tremens." 3. "That's a good idea. There have been good results with the combination of these two drugs." 4. "The only disadvantage would be the exorbitant cost of the MAOI."

answer

1. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis."

question

Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client? Answers: 1. In prone position, to prevent airway blockage 2. In high Fowler's position, to prevent increased intracranial pressure 3. On his or her side, to prevent aspiration 4. In Trendelenburg's position, to promote blood flow to vital organs

answer

3. On his or her side, to prevent aspiration

question

A nurse is planning care for a 13-year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents? Answers: 1. Sertraline (Zoloft) 2. Citalopram (Celexa) 3. Escitalopram (Lexipro) 4. Paroxetine (Paxil)

answer

3. Escitalopram (Lexipro)

question

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client's safety upon discharge?

answer

Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments.

question

A nursing counselor is about to meet with a client suffering from codependency. Which of the following data would further support the assessment of this dysfunctional behavior? (Select all that apply.) Answers: 1. The client can achieve a sense of control only through fulfilling the needs of others. 2. The client is a people pleaser and does almost anything to gain approval. 3. The client has a long history of focusing thoughts and behaviors on other people. 4. The client, as a child, experienced overindulgent and overprotective parents. 5. The client exhibits helpless behaviors but actually feels very competent.

answer

Correct1. The client can achieve a sense of control only through fulfilling the needs of others. Correct2. The client is a people pleaser and does almost anything to gain approval. Correct3. The client has a long history of focusing thoughts and behaviors on other people.

question

A lonely, depressed divorcée has been self-medicating with small amounts of cocaine for the past year. Which term should a nurse use to best describe this individual's situation? Answers: 1. Substance induced disorder 2. Physical addiction 3. Psychological addiction 4. Social induced disorder

answer

3. Psychological addiction

question

A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? Answers: 1. 100 mg/dL 2. 250 mg/dL 3. 300 mg/dL 4. 50 mg/dL

answer

1. 100 mg/dL

question

Which of the following are included in the U.S. Departments of Agriculture and Health and Human Services guidelines to promote health and prevent disease. (Select all that apply.) Answers: 1. Reduce daily sodium intake to 3,000 mg per day. 2. Consume less than 10 percent of calories from saturated fatty acids. 3. Limit total calorie intake to 2,000 mg per day. 4. Limit alcohol consumption to one drink per day for women and two drinks per day for men. 5. Increase physical activity and reduce time spent in sedentary behaviors.

answer

2. Consume less than 10 percent of calories from saturated fatty acids. 4. Limit alcohol consumption to one drink per day for women and two drinks per day for men. 5. Increase physical activity and reduce time spent in sedentary behaviors.

question

A nurse teaches a client about alternative therapies for back pain. When a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, what therapy is the practitioner employing? Answers: 1. Chiropractic therapy 2. Therapeutic touch therapy 3. Massage therapy 4. Allopathic therapy

answer

1. Chiropractic therapy

question

Alternative approaches refer to interventions that are used instead of conventional treatment. A client asks a nurse to explain the difference between alternative and complementary medicine. Which is an appropriate nursing response? Answers: 1. "Complementary medicine disregards traditional medical approaches." 2. "Alternative and complementary medicine are terms that essentially mean the same thing." 3. "Complementary therapies partner alternative approaches with traditional medical practice." 4. "Alternative medicine is a more acceptable practice than complementary medicine."

answer

3. "Complementary therapies partner alternative approaches with traditional medical practice."

question

A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? Answers: 1. "The goal of recovery is the ability to reach full potential." 2. "The goal of recovery is expedient, comprehensive behavioral change." 3. "The goal of recovery is the ability to live a self-directed life." 4. "The goal of recovery is improved health and wellness."

answer

2. "The goal of recovery is expedient, comprehensive behavioral change."

question

A client states, "I have come to the conclusion that this disease has not paralyzed me." The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates? Answers: 1. Preparation 2. Moratorium 3. Rebuilding 4. Awareness

answer

4. Awareness

question

Which situation should a nurse identify as an example of an autocratic leadership style? 1. Without faculty input, the dean mandates that all course content be delivered via the Internet. 2. The president of Sigma Theta Tau assigns members to committees to research problems. 3. During a community meeting, a nurse listens as clients generate solutions. 4. The student nurses' association advertises for candidates for president.

answer

1. Without faculty input, the dean mandates that all course content be delivered via the Internet.

question

An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior? 1. Ignore the act to avoid reinforcing the behavior. 2. Initiate forced medication protocol. 3. With staff support and a show of solidarity, set firm limits on the behavior. 4. Help the client to explore the source of anger.

answer

3. With staff support and a show of solidarity, set firm limits on the behavior.

question

A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to fine when assessing this client? 1. A client who is aware of the need to set goals in life. 2. A client who begins to actively take control of his or her life. 3. A client feeling confident about achieving goals in life. 4. A client who has mobilized personal and external resources.

answer

2. A client who begins to actively take control of his or her life.

question

A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? Answers: 1. "The goal of recovery is the ability to live a self-directed life." 2. "The goal of recovery is improved health and wellness." 3. "The goal of recovery is the ability to reach full potential." 4. "The goal of recovery is expedient, comprehensive behavioral change."

answer

2. "The goal of recovery is improved health and wellness."

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