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193 Cards in this Set

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Dextroamphetamine (Dexedrine) has been ordered for a client diagnosed with narcolepsy. The nurse understands that this medication acts as:
A. an antianxiety agent.
B. a central nervous system (CNS) depressant.
C. a CNS stimulant.
D. a mood stabilizer.
c. Rationale: Dextroamphetamine is a psychostimulant and acts on the CNS. It would increase anxiety and elevate mood. CNS depressants and antianxiety agents would worsen the symptoms of narcolepsy. Mood stabilizers aren't indicated for narcolepsy.
The etiology of schizophrenia is best described by:
A. genetics due to a faulty dopamine receptor.
B. environmental factors and poor parenting.
C. structural and neurobiological factors.
D. a combination of biological, psychological, and environmental factors.
D. Rationale: A reliable genetic marker hasn't been determined for schizophrenia. However, studies of twins and adopted siblings have strongly implicated a genetic predisposition. Since the mid-19th century, excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia. Therefore, a combination of biological, psychological, and environmental factors are thought to cause schizophrenia.
A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should:
A. tell him that she'll leave for now but will return soon.
B. ask him if it's okay if she sits quietly with him.
C. ask him why he wants to be left alone.
D. tell him that she won't let anything happen to him.
a. Rationale: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation.
Clients receiving monoamine oxidase inhibitor antidepressants must avoid tyramine, a compound found in which of the following foods?
A. Aged cheese and Chianti wine
B. Green leafy vegetables
C. Figs and cream cheese
D. Fruits and yellow vegetables
A. Rationale: Aged cheese and Chianti wine contain high concentrations of tyramine. The other foods listed are low in tyramine.
A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:
A. impending coma.
B. manipulating behavior.
C. suppression.
D. perceptual disorders.
D. Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but not a sign of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.
To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:
A. stay with the client and encourage him to eat.
B. help the client fill out his menu.
C. give the client privacy during meals.
D. fill out the menu for the client.
A. Rationale: Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.
A young man is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:
A. antisocial personality disorder.
B. borderline personality disorder.
C. obsessive-compulsive personality disorder.
D. narcissistic personality disorder.
A. Rationale: The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client can't control, even though he realizes they're senseless. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.
A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive-compulsive disorder is associated with:
A. physical signs and symptoms with no organic cause.
B. apprehension.
C. inability to concentrate.
D. repetitive thoughts.
D. Rationale: Obsessive-compulsive disorder is characterized by repetitive thoughts that the client can't control or exclude from consciousness, along with recurring, irresistible impulses to perform a particular action. Physical signs and symptoms with no organic cause typify somatoform disorder. Apprehension and inability to concentrate characterize anxiety disorders.
A client is admitted to the hospital in the manic phase of bipolar disorder. When placing a diet order for the client, which foods would be most appropriate?
A. A bowl of soup, crackers, and a dish of peaches
B. A cheese sandwich, carrot sticks, fresh grapes, and cookies
C. Roast chicken, mashed potatoes, and peas
D. A tuna sandwich, an apple, and a dish of ice cream
B. Rationale: The client may have a difficult time sitting long enough to eat his meal; therefore, finger foods that can be eaten easily are most appropriate. The other foods require the client to sit and eat, a task the client will be unable to achieve at this time.
Two nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which of the following accusations?
A. Assault
B. Battery
C. Neglect
D. Breach of confidentiality
D. Rationale: Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
During a private conversation, a client with borderline personality disorder asks the nurse to "keep my secret" and then displays multiple self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?
A. "This type of behavior requires you to be on suicide precautions."
B. "I'm going to tell your physician. Do you want to tell me why you did that?"
C. "Tell me what type of instrument you used. I'm concerned about infection."
D. "Whenever something important occurs in treatment, the team needs to know about it. I'll have to tell the others, but let's talk about it first."
d. Rationale: This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. The first two responses put the client in a defensive position and may set up a power struggle. The third response ignores the psychological implications of the client's actions.
A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?
A. Provide an unstructured environment for the client.
B. Rotate the nurses who are assigned to the client.
C. Ignore the client's behaviors.
D. Bend unit rules to meet the client's needs.
B. Rationale: Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.
Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs, the nurse should incorporate which of the following instructions in her teaching plan?
A. Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants.
B. Avoid taking antianxiety agents at bedtime.
C. Avoid taking antianxiety agents on an empty stomach.
D. Avoid consuming aged cheese when taking antianxiety agents.
A. Rationale: Potentiating effect refers to a drug's ability to increase the potency of another drug if taken together. Therefore, the client should be instructed to avoid alcohol while taking Librium because it potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Librium comes in capsule form and usually can be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not Librium.
A busy attorney with a successful law practice is admitted to an acute care facility with epigastric pain. Since admission, the client has called the nurse every 15 minutes with one request or another. This client is exhibiting:
A. repression.
B. somatization.
C. regression.
D. conversion.
C> Rationale: The client is exhibiting the defense mechanism of regression — a return to behavior characteristic of an earlier developmental level. Dependent, attention-getting behavior is an attempt to relieve anxiety. Repression would manifest as ignoring the symptoms. Somatization is the channeling of anxiety into a preoccupation with physical complaints. Conversion involves transfer of a mental conflict into a physical symptom to relieve anxiety.
Sedative-hypnotic drugs are used to treat which of the following disorders?
A. Obsessive-compulsive disorder (OCD)
B. Attention deficit hyperactivity disorder (ADHD)
C. Hallucinations and delusions
D. Anxiety and insomnia
D. Rationale: Sedative-hypnotic drugs aren't linked to the treatment of a specific disorder. They're used to treat anxiety and insomnia, which can occur in a range of psychiatric disorders. Antidepressants are used to treat OCD. Psychostimulants are used to treat ADHD. Hallucinations and delusions are treated with antipsychotics.
The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems?
A. Depression is commonly characterized by pain disorders and somatic complaints.
B. Combining evaluations will save time and allow for quicker delivery of health care.
C. Most insurance plans won't cover evaluation of both as separate entities.
D. The physician doesn't have the training to evaluate for psychosocial considerations.
A. Rationale: Psychosocial factors should be suspected when pain persists beyond the normal tissue healing time and physical causes have been investigated. The other choices may or may not be correct but certainly aren't credible in all cases.
A woman seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. She also has aches and pains. A nursing diagnosis for this client might include:
A. Delayed growth and development.
B. Ineffective role performance.
C. Posttrauma syndrome.
D. Chronic low self-esteem
D. Rationale: All symptoms define chronic low self-esteem. There isn't enough information to determine delayed growth and development. The question doesn't describe the client's ability to perform in her roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data in the question.
The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
A. Inadequate diet
B. Divorce
C. Job promotion
D. Adopting a child
A.Rationale: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices — divorce, job promotion, and adopting a child — are considered life events.
The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?
A. Inadequate diet
B. Divorce
C. Job promotion
D. Adopting a child
A. Rationale: Poor, inadequate diet is the only option considered a lifestyle factor. The other choices — divorce, job promotion, and adopting a child — are considered life events.
Which of the following indications is the primary use for electroconvulsive therapy (ECT)?
A. Severe agitation
B. Antisocial behavior
C. Noncompliance with treatment
D. Major depression with psychotic features
D. Rationale: ECT is indicated for depression. ECT isn't indicated for severe agitation, antisocial behavior, or treatment noncompliance.
What is the nurse's most important role in caring for a client with a mental health disorder?
A. To offer advice
B. To know how to solve the client's problems
C. To establish trust and rapport
D. To set limits with the client
C. Rationale: It's extremely important that the nurse establish trust and rapport. The nurse shouldn't offer advice. Instead, she should help the client develop the coping mechanisms necessary to solve his own problems. Setting limits is also important but not as important as developing trust and rapport.
The nurse is caring for a client with bipolar disorder. The plan of care for a client in a manic state would include:
A. offering high-calorie meals and strongly encouraging the client to finish all food.
B. insisting that the client remain active through the day so that he'll sleep at night.
C. allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
D. listening attentively with a neutral attitude and avoiding power struggles.
D. Rationale: The nurse should listen to the client's requests, express willingness to seriously consider the requests, and respond later. High-calorie finger foods should be offered to supplement the client's diet, if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. The nurse should set limits in a calm, clear, and self-confident tone of voice.
The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:
A. turning on the lights and opening the windows so that the client doesn't feel crowded.
B. leaving the client alone.
C. staying with the client and speaking in short sentences.
D. turning on stereo music.
C Rationale: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client’s anxiety.
While in the hospital, a client with obsessive-compulsive disorder saves all used medicine cups and paper cups and arranges them in elaborate sculptures in the room. At home, the client saves mail and magazines and makes elaborate paper sculptures of them. Which outcome would indicate successful inpatient treatment for this client?
A. The client throws away all disposable cups.
B. The client is discharged and takes the cups home.
C. The client creates cup sculptures in the dayroom.
D. The client goes home, on pass, to arrange the magazines
A Rationale: A goal of treatment with obsessive-compulsive clients is to throw away hoarded items. Moving the hoarded items or rearranging them doesn't indicate progress because these actions allow the inappropriate behavior to continue.
A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. Which of the following should be the nurse's overall goal of care?
A. To help the client perform self-care activities
B. To help the client function effectively in her environment
C. To help control the client's symptoms
D. To help the client participate in group therapy
B Rationale: A client with panic disorder typically confines movements to increasingly smaller areas to avoid confronting fears, which may dominate her life and limit everyday activities. The overall goal of care is to help the client function within her environment as effectively as possible. Panic disorder with agoraphobia doesn't impair ability to perform self-care activities. Controlling symptoms isn't the overall goal; furthermore, helping the client function effectively will help control symptoms. Although participation in group therapy may help the client control symptoms, encouraging such participation isn't the overall goal of nursing care.
Before eating a meal, a client with obsessive-compulsive disorder must wash his hands for 18 minutes, comb his hair 444 strokes, and switch the bathroom light on and off 44 times. What is the most appropriate treatment goal for this client?
A. Omit one unacceptable behavior each day.
B. Increase the client's acceptance of therapeutic drug use.
C. Allow ample time for the client to complete all rituals before each meal.
D. Systematically decrease the amount of time spent in — and the number of repetitions of — rituals.
D Rationale: When treating a client with obsessive-compulsive disorder, the goal is to systematically decrease the undesirable behavior. (Therapy may not completely extinguish certain behaviors.) Treatment aims to decrease and ultimately eliminate ritualistic behaviors. Expecting to omit one behavior a day is unrealistic because the client may have used ritualistic behaviors to reduce anxiety for a long time. Drugs are used with caution and in conjunction with individual or group therapy. Allowing time for all rituals perpetuates the undesirable behaviors.
Important teaching for a client receiving risperidone (Risperdal) would include advising the client to:
A. double the dose if missed to maintain a therapeutic level.
B. be sure to take the drug with a meal because it's very irritating to the stomach.
C. discontinue the drug if the client reports weight gain.
D. notify the physician if the client notices an increase in bruising.
D Rationale: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. Don't double the dose. This drug doesn't irritate the stomach, and weight gain isn't a problem.
A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which of the following actions?
A. Administering the medication by injection
B. Omitting the dose and trying again the next day
C. Crushing the medication and putting it in his food
D. Consulting with the physician about a plan of care
D Rationale: To determine plans of care for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, medications can't be forced on a client. A dose shouldn’t be omitted without first checking with the physician. Intentionally deceiving or misleading a client violates the therapeutic relationship.
A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagnosis?
A. Schizophrenia
B. Paranoid personality
C. Bipolar illness
D. Obsessive-compulsive disorder (OCD)
C. Rationale: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Schizophrenia doesn't exhibit mood swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is commonly accompanied by grandiosity. OCD is a preoccupation with rituals and rules.
Conditions necessary for the development of a positive sense of self-esteem include:
A. consistent limits.
B. critical environment.
C. inconsistent boundaries.
D. physical discipline.
A Rationale: A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.
A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
A. Withdrawal
B. Logical thinking
C. Repression
D. Denial
D. Rationale: Denial is an unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.
A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings?
A. Avoid discussing the client's perceptions and feelings.
B. Focus discussions on food and weight.
C. Avoid discussing unrealistic cultural standards regarding weight.
D. Provide objective data and feedback regarding the client's weight and attractiveness
D Rationale: Providing objective data focuses on reality and may help the client develop a more realistic body image and gain self-esteem. Discussing the client's perceptions and feelings would help her identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating. Recognizing unrealistic cultural standards would help the client establish more realistic weight goals.
The third major health problem in the United States is which of the following disorders?
A. Cancer
B. Heart disease
C. Alcoholism
D. Bipolar illness
C Rationale: Alcoholism is the third major health problem in the United States. Between 9 and 10 million people are "problem" drinkers. In addition, alcoholism adversely affects the mental health of 30 million friends and relatives of alcoholics. Heart disease and cancer are the number one and two health problems, respectively, in the United States. Bipolar illness isn't a major illness.
Your client is taking clozapine (Clozaril) and complains of a sore throat. This symptom may be an indication of which of the following adverse reactions?
A. Extrapyramidal reaction
B. Tardive dyskinesia
C. Reye's syndrome
D. Agranulocytosis
D Rationale: The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.
The nurse is caring for a client with disorganized schizophrenia. The client is responding well to therapy but has had limited social contact with others. Which of the following interventions is most appropriate?
A. Discourage the client from interacting with others because if his efforts fail it will be too traumatic for him.
B. Encourage the client to attend a party thrown for the residents of the facility.
C. Encourage the client to participate in one-on-one interactions.
D. Encourage the client to place a personal advertisement in the local newspaper, but not to reveal his mental disability.
C Rationale: First, encourage the client to participate in one-on-one interactions, then progress to small groups to enable the client to practice newly acquired social skills. Discouraging the client from interacting with others would reinforce his social isolation. Encouraging the client to place a personal advertisement is inappropriate.
A client is admitted to the hospital with severe depression after her husband left her. The nurse suspects that the client is at risk for suicide. Which question would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk?
A. "Are you sure you want to kill yourself?"
B. "I know if my husband left me, I would want to kill myself. Is that what you think?"
C. "How do you think you would kill yourself?"
D. "Why don't you just look at the positives in your life?"
C Rationale: To determine if a client is at risk for suicide, ask, "How do you think you would kill yourself?" If the client has a plan, she may be closer to carrying out the act. Option A requires a yes or no response and is self-limiting. In option B, the nurse is telling the client what to think and feel. Option D dismisses the client's feelings.
The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients?
A. By their teeth
B. By body size and weight
C. By looking for Mallory-Weiss tears
D. The clients are indistinguishable upon physical examination.
B Rationale: Behaviors of the anorectic client and the bulimic client are commonly similar, especially because both implement rituals to lose weight; however, the bulimic client tends to eat much more, due to the binge episodes, and therefore can be near-normal weight. Not all persons with the purge disorder have loss of enamel on teeth, especially if the disorder has developed recently. Mallory-Weiss tears are small tears in the esophageal mucosa caused by forceful vomiting, but they aren't always present in bulimic clients.
The nurse is caring for a client with a personality disorder. The client is on a general medical-surgical unit following recent surgery. The nurse deliberately interacts with this client more than she interacts with another client who had the same surgery. Both clients are recovering equally well. Why would the nurse do this?
A. Other caregivers often minimize contact with such clients.
B. The nurse feels sorry for the client.
C. One client has health insurance; the other client doesn't.
D. The nurse suspects that the first client isn't recovering as well as reported.
A Rationale: Because clients with personality disorders are often demanding and difficult, health care providers with little psychiatric experience often try to limit their contact with them. This tends to perpetuate behavioral problems, not improve them. This nurse is acting to balance that trend. Sympathy for a client, lack of health insurance, and unfounded suspicions aren't relevant considerations.
The nurse is caring for a client with a personality disorder. The client is on a general medical-surgical unit following recent surgery. The nurse deliberately interacts with this client more than she interacts with another client who had the same surgery. Both clients are recovering equally well. Why would the nurse do this?
A. Other caregivers often minimize contact with such clients.
B. The nurse feels sorry for the client.
C. One client has health insurance; the other client doesn't.
D. The nurse suspects that the first client isn't recovering as well as reported.
A Rationale: Because clients with personality disorders are often demanding and difficult, health care providers with little psychiatric experience often try to limit their contact with them. This tends to perpetuate behavioral problems, not improve them. This nurse is acting to balance that trend. Sympathy for a client, lack of health insurance, and unfounded suspicions aren't relevant considerations.
A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:
A. highly important or famous.
B. being persecuted.
C. connected to events unrelated to oneself.
D. responsible for the evil in the world.
A Rationale: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.
A client with a history of alcoholism returns to the hospital 3 hours later than the time specified on his day pass. His breath smells of alcohol and his gait is unsteady. What should the nurse say?
A. "Why are you 3 hours late?"
B. "How much did you drink tonight? Drinking is against the rules."
C. "I'm disappointed that you weren't responsible with your day pass."
D. "Please go to bed now. We'll talk in the morning."
D Rationale: The client can best discuss his behavior when he's no longer under the influence of alcohol. Option A encourages the client to invent excuses. Option B is judgmental and discourages open communication, and option C is also judgmental.
Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as:
A. echolalia.
B. palilalia.
C. apraxia.
D. aphonia.
B Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak.
A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:
A. take the client's vital signs.
B. explore the content of the hallucinations.
C. tell him his fear is unrealistic.
D. engage the client in reality-oriented activities.
B Rationale: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities.
A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective coping?
A. Inability to make choices and decisions without advice
B. Showing interest only in solitary activities
C. Avoiding developing relationships
D. Recurrent self-destructive behavior with history of depression
A Rationale: Individuals with dependent personality disorder typically show indecisiveness, submissiveness, and clinging behaviors so that others will make decisions for them. These clients feel helpless and uncomfortable when alone and don't show interest in solitary activities. They also pursue relationships to have someone to take care of them. Although clients with dependent personality disorder may become depressed and suicidal if their needs aren't met, this isn't a typical response.
Which of the following etiologic factors predispose a client to Tourette syndrome?
A. No known etiology
B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics
C. Abnormalities in the structure and function of the ventricles
D. Environmental factors and birth-related trauma
B Rationale: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucleus. The ventricles in the brain, environmental factors, and birth trauma aren't involved.
The nurse is caring for a client who is experiencing an acute confusional state. What are the two most common causes of such a condition?
A. Advanced age and alcohol intake
B. Sensory deprivation and physical challenges
C. Acute schizophrenia and bipolar illness
D. Cardiac arrhythmias and cerebrovascular accidents
C Rationale: Acute schizophrenia and bipolar illness are the two most frequently cited causes of acute confusional states. Advanced age, alcohol intake, and sensory deprivation can cause confusion, but these are more likely to be chronic or subacute causes. Cardiac and cerebral causes are less likely to occur in a psychiatric setting.
A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:
A. check the client's medical record for an order for an I.M. as needed dose of medication for agitation.
B. place the client in full leather restraints.
C. call the physician and report the behavior.
D. remove all other clients from the day room
d Rationale: The nurse's first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other individuals.
The physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the past 6 months. The nurse should take which of the following actions?
A. Administer the medication as ordered.
B. Discontinue the medication.
C. Question the order with the physician.
D. Inform the client that he should discuss the MI with the physician
c Rationale: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question their use in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.
The nurse must assess judgment to determine a client's mental status. Which test best accomplishes this?
A. Interpreting proverbs
B. Spelling words backward
C. Counting by serial sevens
D. Discussing hypothetical ethical situations
D Rationale: Hypothetical ethical situations — such as "What would you do if you found a wallet containing credit cards and identification?" — are used to test judgment. Proverb interpretation tests thinking. Spelling words backward and counting by serial sevens test concentration.
Which classification of drugs is the most potentially fatal if the client takes an overdose?
A. Antihistamines
B. Dopaminergics
C. Phenothiazine antipsychotics
D. Tricyclic antidepressants
D Rationale: Tricyclic antidepressants can create fatal cardiac arrhythmias. Overdose of the other medications is rarely fatal.
A client with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobias include:
A. insomnia and an inability to concentrate.
B. severe anxiety and fear.
C. depression and weight loss.
D. withdrawal and failure to distinguish reality from fantasy
B Rationale: Phobias cause severe anxiety (such as a panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms include profuse sweating, poor motor control, tachycardia, and elevated blood pressure. Insomnia, an inability to concentrate, and weight loss are common in depression. Withdrawal and failure to distinguish reality from fantasy occur in schizophrenia.
A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms?
A. The opportunity to verbalize memories of trauma to a sympathetic listener
B. Family support
C. Prescribed medications taken as ordered
D. Alcoholics Anonymous (AA) meetings
A Rationale: Although talking about their experiences can be difficult, clients with PTSD can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief.
Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?
A. Accept responsibility for own behaviors.
B. Be able to verbalize his own needs and assert rights.
C. Set firm and consistent limits with the client.
D. Allow the child to establish his own limits and boundaries.
A Rationale: Children with oppositional defiant disorder frequently violate the rights of others. They're defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Option B is incorrect as the oppositional child usually focuses on his own needs. Options C and D aren't outcome criteria but interventions.
A voluntary client in a health care facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This is an example of which of the following?
A. False imprisonment
B. Limit setting
C. Slander
D. Violation of confidentiality
A Rationale: Confining a voluntary client against his will may be considered false imprisonment. Slander is oral defamation of character. The nurse hasn't given out any information about the client, so confidentiality hasn't been violated.
The nurse is caring for a client who has a mood disorder. This disorder has a very strong biological and genetic component. What disorder does this client most likely have?
A. Generalized anxiety disorder
B. Adjustment disorder with depressed mood
C. Posttraumatic stress disorder
D. Bipolar disorder
D Rationale: Formerly called manic-depression, bipolar disorder has a genetic link. About 10% of children who have a parent with this disorder will develop it. The other choices have no clear-cut genetic or biological link.
An 89-year-old client is suffering from dementia of the Alzheimer's type. Which intervention would be most useful in managing his dementia?
A. Provide a safe environment.
B. Provide a stimulating environment.
C. Avoid the use of touch.
D. Use restraints whenever necessary.
A Rationale: Providing a safe environment will ensure safety when a client has poor judgment, memory loss, and an unsteady gait. Overactivity and noise can overstimulate a client with dementia of the Alzheimer's type by causing agitation. The use of nonverbal communication techniques, such as touch, convey acceptance to the client and can be comforting. The use of restraints can increase a client's agitation.
Additive central nervous system (CNS) depression can occur when combining a sedative-hypnotic with which of the following drugs?
A. methylphenidate (Ritalin)
B. cocaine
C. amitriptyline (Elavil)
D. amphetamine (Adderall)
C Rationale: Additive effects occur with concomitant use of CNS depressants, antihistamines, antidepressants, and antipsychotics. Elavil is an antidepressant and the only correct answer. All the other drugs are classified as stimulants.
The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous (AA) meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:
A. "You must first stop drinking."
B. "Your physician must refer you to this program."
C. "Admit you're powerless over alcohol and that you need help."
D. "You must bring along a friend who will support you."
C Rationale: The first of the 12 steps of AA is for an individual to admit that he's powerless over alcohol and that life has become unmanageable. Although AA promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a sponsor who may be called upon when the client has the urge to drink.
The nurse is caring for a client who is experiencing auditory hallucinations. What would be most critical for the nurse to assess?
A. Possible hearing impairment
B. Family history of psychosis
C. Content of the hallucinations
D. Possible sella turcica tumors
C Rationale: To prevent the client from harming himself or others, the nurse should encourage the client to reveal the content of auditory hallucinations. Assessing for hearing impairment would be inappropriate. Family history, although important because of a possible genetic component, isn't an immediate concern. Olfactory hallucinations, not auditory hallucinations, are associated with sella turcica tumors.
Which of the following statements accurately describes therapeutic communication?
A. Offering advice and your opinion
B. Refraining from verbalizing your feelings
C. Avoiding advice, judgment, false reassurance, and approval
D. Telling the client how to cope
C Rationale: The goal of therapeutic communication is to help the client develop insight and skills to solve his own problems. This is done by avoiding advice, judgment, false reassurance, and approval. Pointing out mistakes can make a client defensive. The client-nurse relationship isn't the place for the nurse to offer advice or an opinion. It also isn't the place for the nurse to verbalize her own feelings. The client needs assistance in developing coping skills, not someone to solve problems for him.
A therapeutic nurse-client relationship begins with the nurse’s:
A. sincere desire to help others.
B. acceptance of others.
C. self-awareness and understanding.
D. sound knowledge of psychiatric nursing.
C Rationale: Although all of the choices are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior is a prerequisite for understanding and helping clients.
A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, the client may experience:
A. decreased perceptual field.
B. decreased heart rate.
C. decreased respiratory rate.
D. heightened concentration
A Rationale: Panic is the most severe level of anxiety. During a panic attack, the client experiences decreased perceptual field, becoming more focused on himself, less aware of his surroundings, and unable to process information from the environment. The decreased perceptual field contributes to impaired attention and an inability to concentrate. During an acute panic attack, the client may experience increased heart rate and respiratory rate from stimulation of the sympathetic nervous system.
A client in group therapy is restless. His face is flushed and he makes sarcastic remarks to group members. The nurse responds by saying, "You look angry." The nurse is using which of the following techniques?
A. A broad opening statement
B. Reassurance
C. Clarifying
D. Making observations
D Rationale: The nurse is using observation to give the client feedback about his behavior and attitude. A broad statement doesn't give feedback to the client. The nurse didn't ask the client to explain his actions (clarifying) and she didn't reassure the client.
A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:
A. tension and irritability.
B. slow pulse.
C. hypotension.
D. constipation.
A Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.
Benztropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by:
A. decreasing the anxiety causing muscle rigidity.
B. blocking the cholinergic activity in the central nervous system (CNS).
C. increasing the level of acetylcholine in the CNS.
D. increasing norepinephrine in the CNS.
B Rationale: Cogentin blocks the cholinergic activity in the CNS. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.
The nurse is using the CAGE questionnaire as a screening tool for alcohol problems. What do these initials represent?
A. Cut down, Annoyed, Guilty, Eye-opener
B. Consumed, Angry, Gastritis, Esophageal varices
C. Cancer, Alcoholic liver, Gastric ulcer, Erosive gastritis
D. Cunning, Anger, Guilt, Excess
A Rationale: CAGE stands for "Have you felt the need to Cut down on your drinking? Have you ever been Annoyed by criticism of your drinking? Have you felt Guilty about your drinking? Have you felt the need for an Eye-opener in the morning?"
Discharge instructions for clients receiving tricyclic antidepressants include which of the following information?
A. Don't consume alcohol.
B. Discontinue if dry mouth and blurred vision occur.
C. Restrict fluid and sodium intake.
D. It's safe to continue taking during pregnancy.
A Rationale: Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. Fluid and sodium intake must be monitored during lithium (Lithobid) treatment. Safe use during pregnancy and lactation hasn't been established.
Positive symptoms of schizophrenia include which of the following?
A. Hallucinations, delusions, and disorganized thinking
B. Somatic delusions, echolalia, and a flat affect
C. Waxy flexibility, alogia, and apathy
D. Flat affect, avolition, and anhedonia
A Rationale: The positive symptoms of schizophrenia are distortions of normal functioning, including hallucinations, delusions, disorganized thinking, somatic delusions, echolalia, and waxy flexibility. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms list the diminution or loss of normal function.
An agitated client demands to see her chart so she can read what has been written about her. Which of the following statements is the nurse's best response to the client?
A. "I'm sorry the chart is the property of the facility. We don't permit clients to read them."
B. "You have the right to see your chart. Please discuss this with your primary care provider."
C. "You may see your chart after you're discharged."
D. "Please discuss this matter with your attorney."
B Rationale: The Bill of Rights for Psychiatric Clients includes the right for clients to access their medical records unless doing so would be detrimental to their health. To determine if information might be detrimental to the client, the primary care provider should be informed of the client's request. The client doesn't need an attorney to view her chart. She also doesn't need to wait until after discharge to view it.
The nurse is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
A. sedation.
B. diarrhea.
C. vertigo.
D. urticaria.
B Rationale: Diarrhea is a common physiological response to stress and anxiety. The other choices could also be related to stress and anxiety but they don't occur as commonly as diarrhea.
The nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:
A. ask the client which activity he would prefer to do first.
B. negotiate a time when the client will perform activities.
C. tell the client specifically and concisely what needs to be done.
D. prepare the client ahead of time for the activity.
C Rationale: The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and preparing the client ahead of time also aren't therapeutic with this type of client because he may not want to perform the activity.
Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:
A. structured limit setting.
B. supportive environment.
C. abuse and neglect.
D. direction and attention.
C Rationale: Abuse and neglect lead to poor self-concept and role confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive limits and attention.
Unhealthy personal boundaries are a product of dysfunctional families and a lack of positive role models. Unhealthy boundaries may also be a result of:
A. structured limit setting.
B. supportive environment.
C. abuse and neglect.
D. direction and attention.
C Rationale: Abuse and neglect lead to poor self-concept and role confusion, the basis for unhealthy personal boundaries. Healthy boundaries are established in childhood when parents provide consistent, supportive limits and attention.
Which clinical condition meets the criteria for involuntary commitment?
A. A single parent who leaves her minor children unattended and stays out all night drinking
B. A person who lives alone and isn't able to care for himself and has schizophrenia with delusions of persecution
C. A man who threatens to kill his wife
D. A person with depression who says he's tired of living but doesn't have a suicide plan
C Rationale: One of the criteria for involuntary commitment is an emergency in which the client is a threat to himself or others. A parent might have a child removed from the home because of neglect, but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to himself.
The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for:
A. a depressed client.
B. a manic client.
C. a suicidal client.
D. an anxious client.
B Rationale: Setting limits for unacceptable behavior is most important in a manic client. Typically, depressed, suicidal, or anxious clients don't physically or mentally test the limits of the caregiver.
A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which response is most appropriate?
A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you."
B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."
C. "You're wrong. Nobody is trying to kill you."
D. "A foreign government is trying to kill you? Please tell me more about it."
B Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.
A client with a diagnosis of major depression is prescribed clonazepam (Klonopin) for agitation in addition to an antidepressant. Client teaching would include which of the following statements?
A. Klonopin may interact with organ meats.
B. The medications shouldn't be taken together.
C. Klonopin is a minor depressant and may aggravate symptoms of depression.
D. The order needs to be clarified; call the physician.
C Rationale: Klonopin is a central nervous system depressant and can aggravate symptoms in depressed clients. It doesn't interact with organ meats and can be taken with antidepressant medication. There is no need to call the physician; the medications can be safely taken together.
The nurse is caring for a client whom she suspects is paranoid. How would the nurse confirm this assessment?
A. Indirect questioning
B. Direct questioning
C. Lead-in sentences
D. Open-ended sentences
B Rationale: Direct questions (such as "Do you hear voices?" or "Do you feel safe right now?") are the most appropriate technique for eliciting verifiable responses from a psychotic client. The other options may not elicit helpful responses.
A client who recently developed paralysis of the arms is diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the plan of care?
A. Exercising the client's arms regularly
B. Insisting that the client eat without assistance
C. Working with the client rather than the family
D. Teaching the client how to use nonpharmacologic pain-control methods
A Rationale: To maintain the integrity of the affected areas and prevent muscle wasting and contractures, the nurse should perform regular passive range-of-motion exercises to the client's arms. The nurse shouldn't insist that he eat without assistance because he can't consciously control symptoms and move his arms; furthermore, such insistence may anger the client and endanger the therapeutic relationship. The nurse should include family members because they may be contributing to his stress or conflict, and they're essential in helping the client regain function of his arms. Because the client isn't experiencing pain, he doesn't need education about pain management.
Silence in therapeutic communication is:
A. a means of disapproval.
B. to be avoided as it indicates intolerance and anger.
C. a means of allowing the client space in which to respond and communicates patience.
D. not therapeutic.
C Rationale: Silence conveys acceptance and gives the client an opportunity to reflect. It doesn't convey disapproval unless accompanied by hostile gestures. It's one of the most difficult therapeutic communication techniques.
A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which of the following techniques?
A. Presenting reality
B. Making observations
C. Restating
D. Exploring
D Rationale: The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.
Lorazepam (Ativan) is commonly given along with a neuroleptic agent. What is the purpose of administering the drugs together?
A. To reduce anxiety and potentiate the sedative action of the neuroleptic
B. To counteract extrapyramidal effects of the neuroleptic
C. To manage depressed clients
D. To increase the client's level of awareness and concentration
A Rationale: Lorazepam when given along with a neuroleptic such as haloperidol (Haldol) potentiates the sedating effect and is used to treat severely agitated clients. Haloperidol places the client at risk for extrapyramidal effects and, therefore, wouldn't be used to treat extrapyramidal effects. Both drugs can cause depression, so they aren't used to treat depression. Concentration would be decreased because of the depressant effect.
The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client?
A. Assigning him to group activities
B. Reducing his stimulation
C. Assisting him with self-care
D. Helping him express his feelings
B Rationale: Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, these clients can't express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control.
A male client approaches the nurse and says, "Hey cutie, can you take me outside for a smoke?" The nurse is aware that the client isn't supposed to go out to smoke for another 15 minutes. Which response by the nurse is most therapeutic?
A. "Sure, I'm not busy right now."
B. "You can ask the technician. I'm busy right now."
C. "You'll be able to smoke in 15 minutes. Calling me cutie is disrespectful."
D. "You know the rules. It isn't time yet for you to go out to smoke."
C Rationale: The client's behavior indicates that he has difficulty adhering to limits and respecting boundaries. The nurse must place limits on the client's manipulative behavior. Taking the client outside for a smoke is inappropriate because the nurse is allowing the client to manipulate her. Referring the client to the technician is incorrect because the nurse isn't addressing the client's manipulative behavior. Option D is an abrupt response that may cause the client to act defensively.
The nurse is caring for a client diagnosed with paranoid personality disorder in an acute care facility. Which intervention would the nurse use to control the client's suspiciousness?
A. Keeping messages clear and consistent, while avoiding deception
B. Providing pharmacologic therapy
C. Providing social interactions with others on the unit
D. Attending to basic daily needs of the client on a consistent basis
A Rationale: Keeping messages consistent, fostering trust, and avoiding deception will help to decrease suspiciousness; encouraging social interactions and attending to basic daily needs, and providing pharmacologic therapy are general nursing interventions that are appropriate for any psychiatric disorder.
Which of the following is one of the advantages of the antipsychotic medication risperidone (Risperdal)?
A. The absence of anticholinergic effects
B. A lower incidence of extrapyramidal effects
C. Photosensitivity
D. No incidence of neuroleptic malignant syndrome (NMS)
B Rationale: Risperdal has a lower incidence of extrapyramidal effects than the typical antipsychotics. Risperdal does produce anticholinergic effects and NMS can occur. Photosensitivity isn't an advantage.
A 23-year-old client in the manic phase of bipolar disorder is admitted to the facility. Which of the following agents would be appropriate for this client?
A. bupropion (Wellbutrin) and lithium (Lithobid)
B. lithium (Lithobid) and valproic acid (Depakene)
C. haloperidol (Haldol) and fluphenazine (Prolixin)
D. risperidone (Risperdal) and clozapine (Clozaril)
B Rationale: Lithium and valproic acid are the drugs of choice for manic depression. Wellbutrin is an antidepressant, not an antimanic. Haloperidol, fluphenazine, clozapine, and risperidone are antipsychotic agents.
A client reports losing his job, not being able to sleep at night, and feeling upset with his wife. The nurse responds to the client, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique?
A. Restating
B. Making observations
C. Exploring
D. Focusing
D Rationale: The nurse is using focusing by suggesting that the client discuss a specific issue. She didn't restate the question, ask further questions (exploring), and didn't make an observation.
The nurse is caring for a client who believes he has cancer. He has visited several oncologists and undergone many tests. Thus far, no evidence of cancer has been found. The client remains convinced he's gravely ill and tells the nurse he doesn't expect to live much longer. What specific type of disorder is the client exhibiting?
A. Hypochondriasis
B. Dependency
C. Denial
D. Confabulation
A Rationale: Hypochondriasis is marked by a persistent fear or belief that one has a serious illness. Dependency involves expectations that another person should do all the work to change the client from relative illness to health. Denial is lack of awareness and is usually an unconscious defense mechanism. Confabulation is a reaction in which the client invents answers, attempting to fill in memory gaps.
The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:
A. is responding to the antipsychotic.
B. may be experiencing increased energy and is at an increased risk for suicide.
C. is ready to be discharged from treatment.
D. is experiencing a split personality.
B Rationale: As antidepressants take effect, individuals suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Option A is incorrect because Elavil is an antidepressant, not an antipsychotic. Option C is incorrect because the client shouldn't be discharged until the risk of suicide has diminished. Option D indicates a response to the antidepressant, not a split personality.
The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
A. barbiturates.
B. amphetamines.
C. methadone.
D. benzodiazepines.
C Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.
A client in an acute care center lacerates her wrists. She has a history of conflicts and acting out. The client tells the nurse, "I did a good job didn't I?" Which of the following responses would be best?
A. "You sure did. You're going to have a scar now."
B. "How many times have you done this before?"
C. "What were you feeling before you hurt yourself?"
D. "It seems to me you are trying to get attention in a negative way."
C Rationale: Self-mutilation is the client's way of defending herself against feelings she isn't able to express. It's important to shift focus from the mutilation and to help the client express feelings in a more acceptable manner. All other answers are judgmental.
Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)?
A. benztropine (Cogentin) and diphenhydramine (Benadryl)
B. chlordiazepoxide (Librium) and diazepam (Valium)
C. fluvoxamine (Luvox) and clomipramine (Anafranil)
D. divalproex (Depakote) and lithium (Lithobid)
C Rationale: The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. Librium and Valium may be helpful in treating anxiety related to OCD but aren't drugs of choice to treat the illness. The other medications mentioned aren't effective in the treatment of OCD.
Which nursing action is most effective in defusing a client's impending violent behavior?
A. Helping the client identify and express feelings of anxiety and anger
B. Involving the client in a quiet activity to divert attention
C. Leaving the client alone until he can talk about his feelings
D. Placing the client in seclusion
A Rationale: In many instances, the nurse can defuse impending violence by helping the client identify and express feelings of anger and anxiety. Statements such as, "What happened to get you this angry?" may help the client discuss feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of him acting out is too great. The client should be placed in seclusion only if other interventions fail or if he requests this. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and provides a feeling of security.
Hormonal effects of the antipsychotic medications include which of the following?
A. Retrograde ejaculation and gynecomastia
B. Dysmenorrhea and increased vaginal bleeding
C. Polydipsia and dysmenorrhea
D. Akinesia and dysphasia
a Rationale: Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren't hormonal effects.
A nurse is working with a dying client and his family. Which communication technique is most important to use?
A. Reflection
B. Interpretation
C. Clarification
D. Active listening
d Rationale: When working with a dying client and his family, the nurse uses active listening to assess their feelings, coping skills, and immediate and long-term needs. It also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client on the defensive.
A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:
A. an example of presenting reality.
B. reinforcing the client's delusions.
C. focusing on emotional content.
D. a nontherapeutic technique called mind reading.
c Rationale: The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic.
The nurse is teaching a client about healthy interpersonal relationships. Which characteristic would the nurse include?
A. Minimal self-revelation
B. Willingness to risk self-revelation
C. Ego-dystonic behavior
D. Intimacy and merging of identities
b Rationale: Willingness to risk self-revelation, ego-syntonic behavior, and intimacy while maintaining separate identities are all characteristics of healthy interpersonal relationships. (Note that ego-syntonic behavior refers to thoughts, impulses, attitudes, and behavior that are felt to be acceptable and consistent with the client's personality while ego-dystonic behavior refers to thoughts, impulses, attitudes, and behavior that the client feels are distressing, repugnant, or inconsistent with the rest of his personality.)
The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:
A. encourage verbalizations about fears and stressful life situations.
B. agree with the client because she feels a specific physical feature is awful.
C. ignore the comment and talk about less threatening issues.
D. compliment the client on her appearance.
a Rationale: Encouraging the client to discuss stressful life situations helps focus on the underlying issues. The client's preoccupation with a specific physical feature is a means of not coping with life. Ignoring the client or complimenting the client won't be helpful. She won't be able to accept the compliment. Agreeing with her strengthens her problem.
The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which of the following statements best describes the nurse's response?
A. Correct because she didn't give out information about the client
B. A violation of confidentiality because she informed the officer that the client wasn't there
C. A breech of the principle of veracity because the nurse is misleading the officer
D. Illegal because she's withholding information from law enforcement agents
B Rationale: The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
The nurse is caring for a client who exhibits magical thinking. Which of the following best describes magical thinking?
A. Strong positive and negative feelings that cause conflict
B. Returning to an earlier developmental stage
C. Meaningless repetition of words
D. The belief that thoughts or wishes can control other people or events
D Rationale: When a client exhibits magical thinking, he believes that his thoughts or wishes can control others or events. For example, the client may believe that through wishing he can make a plane fall from the sky. Ambivalence is the coexistence of positive and negative thoughts. Returning to an earlier stage of development is termed regression. A meaningless repetition of words is called echolalia.
A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:
A. reassure the client and administer as-needed lorazepam (Ativan) I.M.
B. administer as-needed dose of benztropine (Cogentin) I.M. as ordered.
C. administer as-needed dose of benztropine (Cogentin) by mouth as ordered.
D. administer as-needed dose of haloperidol (Haldol) by mouth.
B Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.
The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. The client states, "I run apple, train, grass, window." This response by the client is known as:
A. echopraxia.
B. a word salad.
C. flight of ideas.
D. neologisms.
B Rationale: A word salad is an illogical word grouping. Echopraxia is an involuntary repetition of movements. Flight of ideas is a rapid succession of unrelated ideas. Neologisms are bizarre words that have meaning only to the client.
For which type of schizophrenia should the nurse expect to provide the most physical care?
A. Disorganized type
B. Catatonic type
C. Paranoid type
D. Undifferentiated type
B Rationale: In catatonic schizophrenia, the client exhibits little reaction to the environment, although periods of excitement may surface at times. Bizarre postures and the inability to feed, wash, and dress oneself are also evident in the catatonic type. Activities of daily living may be affected in varying degrees with the other types but to a lesser extent.
Nursing care for a client after electroconvulsive therapy (ECT) should include:
A. nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B. bed rest for the first 8 hours after a treatment.
C. assessment of short-term memory loss.
D. no special care.
C Rationale: The nurse must assess the level of short-term memory loss. Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. The client might need to be reoriented. The client can get out of bed and eat as soon as he feels comfortable.
A 54-year-old female was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, she was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?
A. Observe for extrapyramidal symptoms.
B. Begin a therapeutic relationship.
C. Cancel any no-suicide contracts.
D. Continue suicide precautions.
D Rationale: As antidepressants begin to take effect and the client feels better, she may have the energy to initiate and complete another suicide attempt. As the client's energy level increases, the nurse must continue to be vigilant to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics and aren't adverse effects of antidepressants. A therapeutic relationship should be initiated upon admission to the psychiatric unit, after suicide precautions have been instituted. Through this relationship the client develops feelings of self-worth and trust and problem-solving takes place. In a no-suicide contract, the client states verbally or in writing that she won't attempt suicide and will seek out staff if she has suicidal thoughts. When the time period for a contract has expired, a new contract should be obtained from the client.
The nurse is caring for a client with late-stage Alzheimer's disease. The client's wife tells the nurse that the client has become very dependent. The client's wife feels guilty if she takes any time for herself because the client cries out for her. The nurse should develop which outcome to assist the client's wife?
A. The caregiver learns to explain to the client why she needs time for herself.
B. The caregiver distinguishes obligations she must fulfill from those that can be controlled or limited.
C. The caregiver leaves the client at home alone for short periods of time to encourage independence.
D. The caregiver avoids asking other family members to help for fear of imposing on them.
B Rationale: The caregiver must learn to distinguish obligations that she must fulfill and limit those that aren't necessary. The caregiver can tell the client when she leaves but she shouldn't expect that the client will remember or won't become angry with her for leaving. The caregiver shouldn't leave the client home alone for any length of time because it may compromise the client's safety. The nurse can provide support to the primary caregiver if she needs to ask other family members for assistance.
A client diagnosed with anxiety disorder is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include which of the following?
A. A warning that immediate sedation can occur with a resultant drop in pulse
B. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug
C. A warning about the incidence of neuroleptic malignant syndrome (NMS)
D. A warning about the drug's delayed therapeutic effect, which is from 14 to 30 days
D Rationale: The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Blood level checks aren't necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported.
The nurse is caring for a bulimic client and an anorectic client. What cognitive characteristics would be similar for both of these clients?
A. Perfectionism, preoccupation with food
B. Relaxed personality, but preoccupied with food
C. No similarities
D. Preoccupation with exercis
A Rationale: Cognitive distortions are similar in both disorders. Rarely do people with eating disorders have relaxed personalities. The anorectic client is more likely than the bulimic client to overexercise for weight control.
The nurse has been caring for a chronic paranoid schizophrenic client for several months, including holding several one-to-one sessions. During one session, the client seems more anxious than usual, speaking rapidly and loudly as the session starts. This behavior indicates a possible change in which form of nonverbal communication?
A. Appearance
B. Kinesics
C. Paralanguage
D. Proxemics
C Rationale: Paralanguage is the use of vocal effects, such as tone and tempo, to convey a message. Appearance refers to the way a person looks. Kinesics involves body language or movement. Proxemics is the use of spatial relationships (the distance between people) during interaction to communicate meaning.
The nurse is caring for a client who exhibits signs of somatization. Which of the following statements is most relevant?
A. Clients with somatization are cognitively impaired.
B. Anxiety rarely coexists with somatization.
C. Somatization exists when medical evidence supports the symptoms.
D. Clients with somatization often have lengthy medical records.
D Rationale: Clients with somatization are prone to "doctor shop" and have extensive medical records as a result of their multiple procedures and tests. Clients with somatization aren't usually cognitively impaired. These clients have coexisting anxiety and depression and no medical evidence to support a clear-cut diagnosis that is causing their symptoms.
The nurse is interviewing a client who is currently under the influence of a controlled substance and shows signs of becoming agitated. What should the nurse do?
A. Use confrontation.
B. Express disgust with the client's behavior.
C. Be aware of hospital security.
D. Communicate a scolding attitude to intimidate the client.
C Rationale: The nurse, for her own protection, should be aware of hospital security and other assisting personnel. The other options may cause a relatively docile client to become belligerent.
The nurse is caring for a client who is sarcastic and critical and often expresses feelings that are the opposite of what he's actually feeling. This client is exhibiting which type of behavior?
A. Passive
B. Aggressive
C. Passive-aggressive
D. Assertive
C Rationale: The person who is passive-aggressive is often sarcastic and critical and expresses feelings that are the opposite of what he actually feels. He defends his rights through resistance. Passive behavior is characterized by denying one's own rights to please others. Aggressive behavior is characterized by trying to violate the rights of others, controlling through humiliation. Assertive behavior is characterized by honest, direct assertion of one's rights through effective communication.
During which phase of alcoholism is loss of control and physiologic dependence evident?
A. Prealcoholic phase
B. Early alcoholic phase
C. Crucial phase
D. Chronic phase
C Rationale: The crucial phase is marked by loss of control and physiologic dependence. The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration.
A client with a history of panic attacks seeks to increase social interaction. Each time the client tries to go to the dayroom, she begins to perspire and becomes short of breath. Which action by the nurse will help ease the client's feelings of panic?
A. Have other clients volunteer to accompany the client.
B. Tell the client she has to overcome her fear.
C. Allow the client to stay in her room.
D. Walk with the client and stay with her while she's in the dayroom.
D Rationale: The client may find security in the presence of a trusted person. Her fears are very real and she'll need the emotional support of caring professionals to overcome them. Telling the client she has to overcome her fears minimizes her feelings. Allowing the client to stay in her room doesn't help the client overcome her feelings of panic.
During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pains, and palpitations. The client also is pale and has a wide open mouth and raised eyebrows. What should the nurse do first?
A. Assist with deep breathing into a paper bag.
B. Orient the client to person, place, and time.
C. Set limits for acting out delusional behaviors.
D. Administer an anxiolytic agent I.M.
A Rationale: Physiologic needs, particularly breathing, are the first priority during a panic attack. Restoring normal breathing patterns should relieve the other symptoms. Orientation usually is unnecessary because most clients respond to external control and reduced stimulation. During a panic attack, the client isn't likely to act out but may strike out if feeling threatened. An anxiolytic agent may be effective but isn't the first priority.
In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurse's best response would be:
A. "Will you briefly summarize your point because others need time also?"
B. "Your behavior is obnoxious and drains the group."
C. To ignore the behavior and allow him to vent.
D. "I'm so frustrated with your behavior."
A Rationale: Option A redirects the client to focus his comments and allows him to make his point. Option B is judgmental, and option C doesn't help facilitate communication. Option D focuses more on the nurse than on the client's need.
The nurse is caring for a client who has a history of alcohol abuse. Why would the client act as if he didn't have a problem?
A. The client has never taken the CAGE questionnaire.
B. Denial is a defense mechanism commonly used by alcoholics.
C. Thought processes are distorted.
D. Alcohol is expensive.
B Rationale: Denial is a defense mechanism commonly used by alcoholics. The CAGE questionnaire is a direct method of discovering whether the client is a substance abuser, but the client is likely to deny the problem regardless of whether he's familiar with this assessment tool. Distorted thought processes and the cost of alcohol are less likely to influence the client's use of denial.
Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions?
A. Use sunscreen because of photosensitivity.
B. Take the antipsychotic medication with food.
C. Have routine blood tests to determine levels of the medication.
D. Abstain from eating aged cheese.
Rationale: Antipsychotics such as haloperidol increase photosensitivity; therefore, clients taking these medications should be warned about the possibility of sunburns. Food restrictions are necessary with monoamine oxidase inhibitors, not antipsychotics such as haloperidol. Routine blood work isn't necessary. Antipsychotic medications can be taken without regard to food intake.
A client in the emergency department complains of suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is assessing the client to determine treatment recommendations. The most important factor to consider is:
A. an active suicide plan and the means to carry it out.
B. a previous suicide attempt.
C. the client's religion and social status.
D. social support and marital status.
A Rationale: The presence of an actual plan would require a restrictive environment for the client. Although a previous suicide attempt, marital status, and social support can affect the rate of suicide, a serious plan is of primary concern for the nurse.
Most antipsychotic medications exert which of the following effects on the central nervous system (CNS)?
A. Stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors.
B. Sedate the CNS by stimulating serotonin at the synaptic cleft.
C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.
D. Depress the CNS by stimulating the release of acetylcholine.
C Rationale: The exact mechanism of antipsychotic medication action is unknown, but it appears to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. They don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.
Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of the following conditions might the drug be administered?
A. Phencyclidine (PCP) intoxication
B. Alcohol withdrawal
C. Opiate withdrawal
D. Cocaine withdrawal
C Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines and neuroleptic agents are typically used to treat PCP intoxication. Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac), are used to treat cocaine withdrawal.
A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?
A. Calcium
B. Sodium
C. Chloride
D. Potassium
B Rationale: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions, but sodium is most important to the absorption of lithium.
A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:
A. a delusion.
B. flight of ideas.
C. ideas of reference.
D. a hallucination.
D Rationale: A hallucination is a sensory perception, such as hearing voices or seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling his ideas or behavior.
Which common substances is the client most likely to inhale to become intoxicated?
A. Glue, cleaning solutions, insecticides
B. Glue, nail polish remover, aerosols
C. Paint thinners, insecticides, spray paint
D. Cleaning solutions, insecticides, spray paint
B Rationale: Glue, nail polish remover, aerosols, paint thinners, and cleaning solutions are inhalants used for a "high." Insecticides inhalation would likely cause illness, and inhaling a spray paint would color the person's face, an obvious detriment.
During the night, a 50-year-old Vietnam veteran with posttraumatic stress syndrome wakens shaking and tells you that someone is trying to smother him. What is the appropriate response for the nurse in this situation?
A. "It was a bad dream. You are safe. I'll stay here with you until you go back to sleep."
B. "We can talk about it tomorrow. Try to see if you can get back to sleep."
C. "It was only a dream. There's nothing to be frightened about."
D. "I'll call the physician and see whether I can get you medication to help you go back to sleep."
A Rationale: The important intervention is to assist the client to feel safe. Staying with him until he's able to sleep again or listening to him if he wants to talk is the most appropriate action for the nurse to take in this situation. Talking about it in the morning won't comfort the client when he's most upset. Stating that it was only a dream trivializes his experience. Calling the physician for a sleeping aide doesn't help the client cope with stress.
An elderly client's lithium level is 1.4 mEq/L. She complains of diarrhea, tremors, and nausea. The nurse's first action is to:
A. hold the lithium (Lithobid) and notify the physician.
B. reassure the client that these are normal adverse effects.
C. administer another lithium dose.
D. discontinue the lithium.
A Rationale: The client has symptoms of lithium toxicity. Therefore, her lithium should be held and the physician notified immediately. These aren't normal adverse effects, and administering another dose would increase the toxic effects. A nurse can't discontinue a medication without a physician's order.
The nurse is preparing to care for a client diagnosed with catatonic schizophrenia. In anticipation of this client’s arrival, what should the nurse do?
A. Notify security.
B. Prepare a magnesium sulfate drip.
C. Place a specialty mattress overlay on the bed.
D. Communicate the client’s nothing-by-mouth status to the dietary department.
C Rationale: The nurse should first focus on meeting the client’s immediate physical needs and preventing complications related to the catatonic state. The need for intervention from security personnel is unlikely. A magnesium sulfate drip isn’t indicated. Nutritional status should be addressed after the client is fully assessed and admitted.
Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?
A. Antipsychotic-induced akathisia and anxiety
B. The manic phase of bipolar illness as a mood stabilizer
C. Delusions for clients suffering from schizophrenia
D. Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior
A Rationale: Propranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic induced akathisia and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.
A client comes to the clinic complaining of the inability to sleep over the past 2 months. He states that his inability to sleep is ruining his life because "getting sleep" is all he can think about. This client is most likely experiencing which sleep disorder?
A. Circadian rhythm sleep disorder
B. Breathing-related sleep disorder
C. Primary insomnia
D. Primary hypersomnia
C Rationale: The client with primary insomnia experiences difficulty initiating or maintaining sleep. A key symptom of primary insomnia is the client's intense focus and anxiety about not getting to sleep. The client diagnosed with circadian rhythm sleep disorder reports periods of insomnia at particular times during a 24-hour period and excessive sleepiness at other times. Excessive sleepiness is the most common complaint of clients affected by breathing-related sleep disorder. The client experiencing primary hypersomnia typically sleeps 8 to 12 hours per night. They fall asleep easily and sleep through the night but often have trouble awakening in the morning.
The nurse is caring for a client hospitalized on numerous occasions for complaints of chest pain and fainting spells, which she attributes to her deteriorating heart condition. No relatives or friends report ever actually seeing a fainting spell. After undergoing an extensive cardiac, pulmonary, GI, and neurologic workup, she's told that all test results are completely negative. The client remains persistent in her belief that she has a serious illness. What diagnosis is appropriate for this client?
A. Exhibitionism
B. Somatoform disorder
C. Degenerative dementia
D. Echolalia
B Rationale: Somatoform disorders are characterized by recurrent and multiple physical symptoms that have no organic or physiologic base. Exhibitionism involves public exposure of genitals. Degenerative dementia is characterized by deterioration of mental capacities. Echolalia is a repetition of words or phrases.
A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action?
A. Assess and stabilize the client’s medical needs.
B. Assess and stabilize the client’s psychological needs.
C. Attempt to locate the nearest family member to get an accurate history.
D. Arrange a transfer to the nearest medical facility.
A Rationale: The possibility of frostbite must be evaluated before the other interventions. Options B, C, and D don’t address the client’s immediate medical needs.
The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:
A. dilated pupils and slurred speech.
B. rapid speech and agitation.
C. dilated pupils and agitation.
D. euphoria and constricted pupils.
D Rationale: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.
A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?
A. Word salad
B. Tangential
C. Perseveration
D. Avolition
D Rationale: Avolition refers to an impairment in the ability to initiate goal-directed activity. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential is when a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions.
A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband says he grew up in a household where his father frequently abused his mother and him. When intervening with this couple, the nurse knows they're at risk for repeated violence because the husband:
A. has only moderate impulse control.
B. denies feelings of jealousy or possessiveness.
C. has learned violence as an acceptable behavior.
D. feels secure in his relationship with his wife.
C Rationale: Family violence usually is a learned behavior, and violence begets violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.
A physician schedules an invasive procedure for a client with acquired immunodeficiency syndrome–related dementia. He lives with his male companion, who is present. His mother, who lives in another state, is also present. The nurse anticipates that the consent form should be signed by:
A. the companion.
B. the mother.
C. the client.
D. two physicians.
B Rationale: The mother should sign the consent form because she's the closest living relative. The client can't sign because of his diagnosis. The companion, although a close significant other, can't sign because he isn't a blood relative. Two physicians need not sign a consent form when a relative is available.
Assertive behavior involves which of the following elements?
A. Saying what is on your mind at the expense of others
B. Expressing an air of superiority
C. Avoiding unpleasant situations and circumstances
D. Standing up for your rights while respecting the rights of others
D Rationale: The basic element of assertive behavior includes the ability to express your feelings and thoughts while respecting the rights of others. Options A and B describe aggressive behavior, and option C describes passive behavior.
A client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the Alzheimer's type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer's disease, the nurse should observe the client for:
A. occasional irritable outbursts.
B. impaired communication.
C. lack of spontaneity.
D. inability to perform self-care activities.
B Rationale: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimer's disease. During the early stage of this disease, subtle personality changes also may be present. However, other than occasional irritable outbursts and lack of spontaneity, the client usually is cooperative and exhibits socially appropriate behavior. Signs of advancement to the middle stage of Alzheimer's disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses. During the late stage, the client can't perform self-care activities and may become mute.
A client who is taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic therapy?
A. Agranulocytosis
B. Extrapyramidal effects
C. Anticholinergic effects
D. Neuroleptic malignant syndrome (NMS)
D Rationale: A rare but potentially fatal condition of antipsychotic medication is called NMS. It generally starts with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism. Anticholinergic effects include blurred vision, drowsiness, and dry mouth.
The nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
A. Tachycardia
B. Warm, flushed extremities
C. Parotid gland tenderness
D. Coarse hair growth
C Rationale: Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.
A client complains of experiencing an overwhelming urge to sleep. He states that he's been falling asleep while working at his desk. He reports that these episodes occur about five times daily. This client is most likely experiencing which sleep disorder?
A. Breathing-related sleep disorder
B. Narcolepsy
C. Primary hypersomnia
D. Circadian rhythm disorder
B Rationale: Narcolepsy is characterized by irresistible attacks of refreshing sleep that occur two to six times per day and last for 5 to 20 minutes. The client with breathing-related sleep disorder suffers interruptions in sleep that leave the client with excess sleepiness. In hypersomnia, the client suffers excess sleepiness and reports prolonged periods of nighttime sleep or daytime napping. With circadian rhythm disorder, the client has periods of insomnia followed by periods of increased sleepiness.
The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
A. Has perceptions based on reality
B. Assumes responsibility for actions
C. Generates new levels of awareness
D. Has maximum ability to solve problems and learn new skills
C Rationale: Adults between ages 31 and 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults between ages 20 and 30.
Touching other people without their permission, reading someone else's mail, and using personal possessions without asking permission are all examples of:
A. antisocial behavior.
B. manipulation.
C. poor boundaries.
D. passive-aggressive behavior.
C Rationale: The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
The nurse's goal in crisis intervention is to provide:
A. problem-solving techniques and structured activities.
B. an insight-oriented analytic approach.
C. medication to sedate the client.
D. nondirective techniques such as free association.
A Rationale: Individuals in a crisis need immediate assistance. They're unable to solve problems and need structure and assistance in accessing resources. Clients in a crisis don't need lengthy explanations or have time to develop insight on their own. They might need medication but, in most cases, support and direction can be most helpful.
A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
A. an increased response to a medication.
B. a diminished response to a drug so that more is required to reach the same effect.
C. an allergic reaction to a medication.
D. an ability to take the same drug for extended periods of time.
B Rationale: Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.
Emergency restraints or seclusion may be implemented without a physician's order under which of the following conditions?
A. When a written order will be obtained from the primary physician within 1 hour
B. Never
C. If a voluntary client wants to leave against medical advice
D. When a minor child is out of control
A Rationale: The primary physician in charge of a client's care must write an order for the restraint within 1 hour. In an emergency, a client who is a threat to himself or others may be restrained without an order. Voluntary clients have the right to leave against medical advice. A minor is treated the same as an adult regarding restraints.
The nurse is caring for a client who has been binge eating. Which of the following descriptions of the client's behavior is most appropriate?
A. The client has been slowly consuming a large amount of food over 3 hours.
B. The client has been rapidly consuming a large amount of food.
C. The client became extremely hungry and then consumed a large amount of food.
D. The client is extremely thin but still highly concerned about her weight.
B Rationale: Binge eating is the rapid consumption of a large amount of food over a given period of time. Hunger doesn't directly affect binge eating associated with mental health disorders. Bulimic people aren't necessarily thin; in fact, they're usually of normal body size and, in many cases, slightly overweight before the onset of the disorder.
A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:
A. not occur at all because the time period for their occurrence has passed.
B. begin anytime within the next 1 to 2 days.
C. begin within 2 to 7 days.
D. begin after 7 days.
B Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Alcohol withdrawal delirium may occur 2 to 4 days — even up to 7 days — after the last drink.
A 16-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:
A. violence on television.
B. passive parents.
C. an internal locus of control.
D. a single-parent family.
A Rationale: Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence.
When caring for an adolescent client diagnosed with depression, the nurse should remember that depression manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include:
A. helplessness, hopelessness, hypersomnolence, and anorexia.
B. truancy, a change of friends, social withdrawal, and oppositional behavior.
C. curfew breaking, stealing from family members, truancy, and oppositional behavior.
D. hypersomnolence, obsession with body image, and valuing of peers' opinions
B Rationale: In adolescents, depression typically manifests as truancy, a change of friends, social withdrawal, and oppositional behavior. In adults, it usually produces helplessness, hopelessness, hypersomnolence, and anorexia. Drug use may lead to curfew breaking, stealing, truancy, and oppositional behavior. It's normal for adolescents to display hypersomnolence, an obsession with body image, and valuing of peers' opinions.
Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?
A. Occurrence of increased libido due to medication adverse effects
B. Increased incidence of dysmenorrhea while taking the drug
C. Continuing previous use of contraception during periods of amenorrhea
D. Instruction that amenorrhea is irreversible
C Rationale: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn't indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and libido generally decreases because of the depressant effect.
The nurse is caring for a client who was found huddled in her apartment by the police. The client stares toward one corner of the room and seems to be responding to something not visible to others. She appears hyperalert and scared. How would the nurse assess the situation?
A. The client may be hallucinating.
B. The client is suicidal.
C. Nothing is wrong because the client isn't a threat to society.
D. The client is malingering.
A Rationale: The scenario is typical of a client who is hallucinating. Not enough information is available to suggest that she's a threat to herself or to society. Malingering refers to a medically unproven symptom that is consciously motivated.
A client with a history of polysubstance abuse is admitted to the health care facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?
A. Alcohol withdrawal
B. Cannabis withdrawal
C. Cocaine withdrawal
D. Opioid withdrawal
D Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.
The charge nurse in an acute care setting assigns a client, who is on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:
A. poor nursing practice because a registered nurse should work with this client.
B. reasonable nursing practice because one-to-one requires the total attention of a staff member.
C. outside the responsibility of an aide.
D. illegal to delegate to an aide.
B Rationale: A psychiatric aide can sit with the client and provide safety. The nurse is still responsible for assessing the client and ensuring that one-to-one supervision occurs. Aides are capable of providing one-to-one observation. It isn't illegal to delegate observation to an aide.
The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?
A. "I'm not permitted to discuss her progress."
B. "I'll give you the name and telephone number of her physician."
C. "I'll have her call you."
D. "I can't confirm whether your employee is a client here."
D The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response?
A. "I'm not permitted to discuss her progress."
B. "I'll give you the name and telephone number of her physician."
C. "I'll have her call you."
D. "I can't confirm whether your employee is a client here."
A 78-year-old client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:
A. forget to eat.
B. not change his position often.
C. exhibit acquiescent behavior.
D. wander.
D Rationale: A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the nurses' station makes it easier to monitor him and ensure his safety should he begin to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change his position often, or change his behavior.
The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
A. delusions.
B. hallucinations.
C. loose associations.
D. neologisms.
B Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are words that have meaning only to the client.
The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:
A. delirium.
B. depression.
C. excessive drug use.
D. Alzheimer's disease.
D Rationale: Alzheimer's disease is the most common cause of dementia in the elderly. About 5% of people over age 65 have severe cases of Alzheimer's disease, and about 12% of people over age 65 have mild or moderate cases of the disease. Delirium, or acute confusion, is caused by an underlying disease and isn't itself a cause of dementia. Depression is common in the elderly but often manifests itself in apathy, self-deprecation, or inertia — not dementia. Excessive drug use, often stemming from the client seeing multiple physicians who are unaware of drugs that other physicians have prescribed, can cause dementia. Although drug misuse is a problem among the elderly, it isn't as common as Alzheimer's disease.
The nurse is caring for a client with borderline personality disorder. Which interventions should the nurse perform?
A. Setting limits on manipulative behavior
B. Allowing the client to set limits
C. Using restraints judiciously
D. Encouraging acting out behavior
A Rationale: Setting limits on manipulative behavior provides the structure that the client needs. Encouraging acting out behavior and allowing the client to set limits would be contraindicated. The need for restraints in a client with borderline personality disorder would be rare, unless coexisting disorders exist.
The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should:
A. give him privacy in the bathroom.
B. allow him to shave.
C. open the window and allow him to get some fresh air.
D. observe him.
D Rationale: The nurse has a responsibility to observe continuously the acutely suicidal client — not provide privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse will naturally prevent hanging or other injury. The nurse will check the client's area and fix dangerous conditions, such as exposed pipes and windows without safety glass. The nurse will also remove potentially dangerous objects such as belts, razors, suspenders, glass, and knives.
Which of the following statements is a guideline to help nurses avoid liability?
A. Follow every physician's order.
B. Do what the client desires even though you may disagree.
C. Practice within the scope of the Nurse Practice Act.
D. Obtain malpractice insurance.
C Rationale: The Nurse Practice Act outlines acceptable standards for nursing. Practicing within those guidelines will protect the nurse from liability. The client doesn't know standards of care and isn't responsible for the nurse's actions. Physicians may not be aware of guidelines for nurses and delegate inappropriate treatment or practice for the nurse. Insurance won't prevent a liability suit, but only assist the nurse if a suit would be filed.
The nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client?
A. The client has regular obsessions.
B. Relaxation techniques and psychotherapy are necessary for cure.
C. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder.
D. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months.
D Rationale: Constant patterns of anxiety that affect the client for more than 6 months and interfere with normal activities are characteristic of generalized anxiety disorder. Frequently, pharmaceutical therapy with benzodiazepines can help. Clients having regular obsessions are probably suffering from obsessive-compulsive disorder. Nightmares and flashbacks are typical symptoms of posttraumatic stress disorder.
A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response?
A. Say, "You know it's your medicine."
B. Allow him to open the individual wrappers of the medication.
C. Say, "Don't worry about what is in the pills. It's what is ordered."
D. Ignore the comment because it's probably a joke.
B Rationale: Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Options C and D aren't supportive and don't offer the client reassurance.
Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime.
B. Ask the client each morning to describe the quality of sleep during the previous night.
C. Teach the client relaxation techniques, such as guided imagery, meditation, and progressive muscle relaxation.
D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
D Rationale: The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill, such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common-sense interventions fail.
Which is the drug of choice for treating Tourette syndrome?
A. fluoxetine (Prozac)
B. fluvoxamine (Luvox)
C. haloperidol (Haldol)
D. paroxetine (Paxil
C Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome.
The nurse is assessing an elderly client for dementia. Which of the following is a primary symptom of dementia?
A. Psychosis
B. Memory loss
C. Neurosis
D. Loss of impulse control
B Rationale: Memory loss is the primary symptom of dementia. Loss of short-term memory (retaining new information) is more prominent, but long-term memory (recollection of events that occurred in the past) may also be affected. Psychosis, neurosis, and loss of impulse control aren't symptoms of dementia.
During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:
A. somatic delusions.
B. waxy flexibility.
C. neologisms.
D. nihilistic delusions.
B Rationale: The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.
A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders?
A. Personality disorder
B. Mood disorder
C. Thought disorder
D. Amnestic disorder
B Rationale: According to the DSM-IV, schizoaffective disorder refers to clients suffering from schizophrenia with elements of a mood disorder, either mania or depression. The prognosis is generally better than for the other types of schizophrenia, but it's worse than the prognosis for a mood disorder alone. Option A is incorrect because personality disorders and psychotic illness aren't listed together on the same axis. Option C is incorrect because schizophrenia is a major thought disorder and the question asks for elements of another disorder. Option D is incorrect because clients with schizoaffective disorder aren't suffering from schizophrenia and an amnestic disorder.
A client with obsessive-compulsive disorder tells the nurse that he must check the lock on his apartment door 25 times before leaving for an appointment. The nurse knows that this behavior represents the client's attempt to:
A. call attention to himself.
B. control his thoughts.
C. maintain the safety of his home.
D. reduce anxiety.
D Rationale: A compulsion is a repetitive act or impulse. Carrying out a compulsion helps a person to reduce anxiety unconsciously. An obsessive-compulsive client doesn't want to call attention to himself and can't control his thoughts. This client's priority is to reduce anxiety, not maintain the safety of his home.
Which of the following statements describes how elderly clients react to medications?
A. At risk for increased adverse effects
B. Tolerate medication better because they're less active
C. Metabolize medications quickly
D. Need higher doses to respond to the same medication
A Rationale: As individuals become older, their livers metabolize drugs at a slower rate. Cumulative effects can occur and increase the risk of adverse effects. Elderly clients typically need lower doses not higher. Level of activity typically doesn't affect a person's reaction to medication.
Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder?
A. An overbearing mother
B. Rejection by peers
C. A history of schizophrenia in the family
D. Low socioeconomic status
B Rationale: Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Aggression and conduct disorder are represented in all socioeconomic groups. Schizophrenia and an overbearing mother haven't been associated with aggression or conduct disorder.
Which of the following statements should be included when teaching clients about monoamine oxidase (MAO) inhibitor antidepressants?
A. Don't take prescribed or over-the-counter medications without consulting the physician.
B. Avoid strenuous activity because of the cardiac effects of the drug.
C. Have blood levels screened weekly for leukopenia.
D. Don't take with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).
A Rationale: MAO inhibitor antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. It's imperative that a client checks with his physician and pharmacist before taking any other medications. Activity doesn't need to be limited. Blood dyscrasias aren't a common problem with MAO inhibitors. Aspirin and NSAIDs are safe to take with MAO inhibitors.
Which of the following drugs may be abused because of tolerance and physiologic dependence?
A. lithium (Lithobid) and divalproex (Depakote)
B. verapamil (Calan) and chlorpromazine (Thorazine)
C. alprazolam (Xanax) and phenobarbital (Luminal)
D. clozapine (Clozaril) and amitriptyline (Elavil)
C Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.
A client with agoraphobia experiences severe panic attacks when attempting to leave the house. This client's outpatient treatment plan includes behavioral therapy to systematically decrease the amount of anxiety that occurs when leaving the house. Which statement best reflects successful therapy?
A. The client leaves the house and experiences palm sweating.
B. The client leaves the house and experiences shortness of breath.
C. The client leaves the house and controls anxiety with an anxiolytic agent.
D. The client stands outside the door to the house and holds onto the doorknob
A Rationale: Getting the client to leave the house is the goal of therapy. Sweating palms is a sign of tolerable, mild anxiety. Shortness of breath indicates intolerable, moderate- to high-anxiety. Using anxiolytic agents to control anxiety regularly isn't desirable because of their addictive potential. Standing outside the door and holding onto the doorknob may be an early intervention, but it isn't the ultimate goal.
The nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior?
A. By designating times during which the client can focus on the behavior
B. By urging the client to reduce the frequency of the behavior as rapidly as possible
C. By calling attention to or attempting to prevent the behavior
D. By discouraging the client from verbalizing anxieties
A Rationale: The nurse should designate times during which the client can focus on compulsive behavior or obsessive thoughts. Frequency of the compulsive behavior should be reduced gradually, not rapidly. The nurse shouldn't call attention to or prevent the behavior; doing so may cause pain and terror in the client. Encouraging the client to verbalize anxieties may help distract his attention from the compulsive behavior.
A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity caused by antipsychotic medication by:
A. blocking dopamine receptors in the central nervous system (CNS).
B. blocking acetylcholine in the CNS.
C. activating norepinephrine in the CNS.
D. activating dopamine receptors in the CNS.
D Rationale: Extrapyramidal effects and the muscle rigidity induced by antipsychotic medications is caused by a low level of dopamine. Dopamine receptor agonists stimulate dopamine receptors and thereby reduce rigidity. They don't affect norepinephrine or acetylcholine.
Nursing implications for a client taking central nervous system (CNS) stimulants include monitoring the client for which of the following conditions?
A. Hyperpyrexia, slow pulse, and weight gain
B. Tachycardia, weight loss, and mood swings
C. Hypotension, weight gain, and listlessness
D. Increased appetite, slowing of sensorium, and arrhythmias
B Rationale: Stimulants produce mood swings, weight loss, and tachycardia. The other symptoms indicate CNS depression.
When teaching a client about lithium (Lithobid), the nurse should instruct the client to:
A. drink at least six to eight glasses of water per day and to avoid caffeine.
B. limit the use of salt in his diet.
C. discontinue medicine when feeling better.
D. increase the amount of sodium in his diet.
A Rationale: Caffeine should be avoided because it increases urine output. Clients need to maintain adequate fluid intake to avoid lithium toxicity. Clients should remain on medication even though they're feeling better. Don't limit or increase salt intake because the kidneys will hold onto lithium or excrete it if salt intake varies.
A nurse places a client in full leather restraints. How often must the nurse check the client's circulation?
A. Once per hour
B. Once per shift
C. Every 10 to 15 minutes
D. Every 2 hours
Rationale: Circulatory as well as skin and nerve damage can occur within 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.
The nurse is caring for a client who has a personality disorder. Which of the following assessment findings should the nurse expect?
A. Manipulative behavior and inflated feelings of self-worth
B. Manipulative behavior and inability to tolerate frustration
C. Suicidal ideation and starvation
D. Patterns of bulimia and starvation
B Rationale: Manipulative behavior and inability to tolerate frustration are important assessment clues. Low self-esteem — not inflated feelings of self-worth — are more likely in clients with personality disorders. The other choices are more likely to be assessed in clients with eating disorders.
Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?
A. Monthly blood tests will be necessary.
B. Report a sore throat or fever to the physician immediately.
C. Blood pressure must be monitored for hypertension.
D. Stop the medication when symptoms subside.
B Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/ìl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician.
During the admission interview, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, "Do you think I will ever get better? I don't know what is wrong with me." The nurse's most supportive response would be:
A. "It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal."
B. "I'm not sure what is wrong, but the medication will help you soon enough."
C. "It's important to talk to your physician about an issue such as this."
D. "Don't feel bad; the treatment will help you."
A Rationale: Option A is the most supportive statement. The nurse acknowledges the client's traumatic experience and pain as well as encourages her to talk. Option B ignores the client's need for reassurance. Option C indicates that the nurse isn't capable of helping the client deal with therapeutic issues. Option D could make the client feel guilty for being upset about the trauma.
A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?
A. "You don't have to eat. It's your choice."
B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable."
C. "Why do you think you're fat? You're underweight. Here — look in the mirror."
D. "You really look terrible at this weight. I hope you'll eat."
B Rationale: Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse is informing her of her treatment options. Option A doesn't tell the client about the consequences of choosing not to eat. Because a client with an eating disorder usually has a distorted self-concept and low self-esteem, options C and D are incorrect because they won't change the client's self-image.
The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder (PTSD). Signs and symptoms of PTSD include:
A. hyperalertness and sleep disturbances.
B. memory loss of traumatic event and somatic distress.
C. feelings of hostility and violent behavior.
D. sudden behavioral changes and anorexia.
A Rationale: Signs and symptoms of PTSD include hyperalertness, sleep disturbances, exaggerated startle, survival guilt, and memory impairment. Also, the client relives the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren't usual signs or symptoms of PTSD.
The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
A. avoid shopping for large amounts of food.
B. control eating impulses.
C. identify anxiety-causing situations.
D. eat only three meals per day.
C Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.
A client recently lost an important advertising account and had a flat tire while driving home. That evening, he began to find fault with everyone. Which defense mechanism was the client using?
A. Displacement
B. Projection
C. Regression
D. Sublimation
A Rationale: Displacement is a defense mechanism by which the client discharges anger and rejection in a manner that he perceives as safe — in this situation, by displacing anger over work and car problems onto family members. Projection involves attributing one's own emotions to others. Regression is a retreat to earlier levels of developmental behavior to relieve anxiety. Sublimation is the socially acceptable discharge of psychic energy or anger, such as through exercise or some other productive activity.
The goal of crisis intervention is:
A. to solve the client's problems for him.
B. psychological resolution of the immediate crisis.
C. to establish a means for long-term therapy.
D. to provide a means for admission to an acute care facility.
B Rationale: The goal of crisis intervention is the resolution of an immediate problem. The client must learn to solve his own issues. Although some clients do enter long-term therapy or are admitted to an acute care facility, long-term therapy isn't the goal of crisis intervention.
client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5Œ8 and weighs only 103 lb, she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client?
A. Teach the client about nutrition, calories, and a balanced diet.
B. Establish a trusting relationship with the client.
C. Discuss cultural stereotypes regarding thinness and attractiveness.
D. Explore the reasons why the client doesn't eat.
B Rationale: A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client's feelings and thoughts. The anorexic client may spend many hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't reinforce her preoccupation with food. Although cultural stereotypes may play a prominent role in anorexia nervosa, discussing these factors isn't the first action the nurse should take. Exploring the reasons why the client doesn't eat would increase her emotional investment in food and eating.
The nurse is aware that antipsychotic medications may cause which of the following adverse effects?
A. Increased production of insulin
B. Lower seizure threshold
C. Increased coagulation time
D. Increased risk of heart failure
B Rationale: Antipsychotic medications exert an effect on brain neurotransmitters that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect of antipsychotic agents.
The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?
A. Restrict visits with the family until the client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her anxiety.
C Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.
The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?
A. Restrict visits with the family until the client begins to eat.
B. Provide privacy during meals.
C. Set up a strict eating plan for the client.
D. Encourage the client to exercise, which will reduce her anxiety.
C Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.
The definition of nihilistic delusions is:
A. a false belief about the functioning of the body.
B. a belief that the body is deformed or defective in a specific way.
C. false ideas about self, others, or the world.
D. the inability to carry out motor activities.
C Rationale: Nihilistic delusions are false ideas about self, others, or the world. Somatic delusions involve a false belief about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.
A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:
A. psychotherapy.
B. total abstinence.
C. Alcoholics Anonymous (AA).
D. aversion therapy.
B Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.