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54 Cards in this Set

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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.
Client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5ft8in 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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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 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.
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.
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.
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.
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
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.
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 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.
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
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.
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
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 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
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.
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.
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.
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.
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.
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.
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.
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 community health nruse visits a client at home. the client sttes, "I haven't slept at all the last couple of nights." Which response by the nruse illustrates the most therapeutic communication tech. for this client?
1."go on...'
3."the last couple of nights?"
4."Your're having difficulty sleeping?"
4. the most therapeutic nusing communication technique is restatement.
A client admitted to the mental health unit is experiencing Altered Thought Processes. The client believes the food is being pisoned. Which comminication tech. does teh nurse plan to use to encourage the clent to eat?
1. use open-ended ?'s and silence
2. offering oopinions about the necessithy of adequate nutrition
3. identifying thereasons that the cleint may no want to eat
4. focusing on self-disclosure about food preferences
1. open-ended ?'s and silence are strategies used to encourag eclients to discuss their problem.
Laboratory work is peresecribed for a client who has been experienceing delusions. When the nurse approaches the clent to obtain a speciment of the the clien's blood, the clent begins to shout, "Your' arll vampires. Let me out of there!" The most appropriate nursing response is which of the folowing?
1. I am not going to hurt you, I am goint ot help you!
2.what makes you think that I am a vampire/
3. ill leve and come back later for your blood.
4. it must be fearful to think other want to hurt you.
4 this lets client focus on the emotion underlying the delusion but does not argue with it.
Important teaching for a cleint receiveing risperidone (Risperdal) would include adivising the client to:
Notify Physician if an increase brusing occurs
A client who is taking antipsychotic medication develops a very high T, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. the snurse suspects what complication of antipsychotic therapy?
Neuroleptic malignant syndrome. a rare but potentially fatal condition of antipsychotic medication.
Benztropine (Cogentin) is used to treat extrapyramidal effects induced by antipsychotics. this durg exerts its effect by:
blocking the cholinergic activity in the CNS.
A schizophrenic clinet is taking clozapine (Clozaril) what S/S should the client report?
A sore throat or fever. These are indication of an infection caused by agranuylocytosis.If the WBC is <3,000/ul the medication must be stopped. <HTN may occur. If medication must be stopped it should be slowly tapered over 1 to 2 weekds and only under supervision.
A client is experiencing an acute confusional state. What are the two most comon causes of such a condition?
Acute schizophrenia and bipolar illness
Lithium is similar to what chemical in the body?
Na. if Ns levels are reduced such as from sweating or diuresis the kidneys will abosrb Lithium and toxicity is a possiblity.
What are the signs and adolescent displays?
truancy, change of friends, social withdrawal, and oppositional behavior.
A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the followin disorder?
A. personality disorder
B.Mood disorder
C. thought disorder
D. Amnestic disorder
B. Mood disorder
Propranolol(Inderal) is used to treat what disorder?
antipsychotic-induce akathisia and anxiety.
23yr old in the manic phase of bipolar disorder is admitted to the facility,. which of the foolowing agenents would be appropriat for this client?
a. bupropion (Wellbitrin) and lithium (Lithobid)
b. lighium (lithobid) and valproic acid (Depakene)
c. haloperidol (Haldol) and fluphenazine (Prolixin)
d. risperidone (Risperdal) and clozapine (Clozaril)
Lithium (Lithobid) and valproic acid (Depakene)
Wellburin is an antidepressant.
Haloperidol, fluphenazine, clozapine and risperidone are antipsychotic agents.
Define nihilistic delusions:
false ideas about self, others, or the world.
Define Somatic delusions:
false belief about the functioning of the body.
Define Aparazia :
inability to carry out motor activities.
s/S of primary dementia of the Alzheimer's type.
slight memory impairment and poor concentration, subtle personality changesand occasional ierritalbe aoutburst and lack of spontaneity
S/S of middle stage demetia of Alzheimers type:
exacerbated cognitive impairment with obsious personality changes and impaired communication, such as inappropriat conversation, actions adn responses.
What is paralanguage?
use of vocal effects, such as tone and tempo, to convey a message.
Most antipsychot meds exert what effect on the CNS?
Block the transmission of three neurotrasmitters: dopamine, serotonin, and norrepinephrine.
bromocriptine (Parlodel) relives muscle rigidity caused by antipsychotic meds by what action?
activating dopamine recepotrs in the CNS.