Exam 2

Question 1

What should be included in the plan of care for a client who has bipolar disorder and is experiencing a manic episode?

Answer 1

• offer concise explanations
• establish consistent limits
• use a firm approach with communication

Question 2

What would indicate that the nursing student has correct understanding of ECT for treatment in bipolar disorder?

Answer 2

“ECT is effective for clients who are experiencing severe mania”

Question 3

What is a priority nursing action for a client who has bipolar disorder?

Answer 3

monitor the client for escalating behavior

Question 4

What education should the nurse provide about relapse prevention in a client who has bipolar disorder?

Answer 4

• difficulty sleeping can indicate a relapse
• participating in psychotherapy can help prevent a relapse
• anhedonia is a manifestation of depressive relapse (lack of interest)

Question 5

If a client with a psychotic disorder is experiencing auditory hallucinations and says “the voices won’t leave me alone!,” what are some things the nurse should say?

Answer 5

• when did you start hearing these things?
• it must be scary to hear these voices
• are the voices telling you to hurt yourself

Question 6

what should the nurse consider as positive symptoms in a patient who has schizophrenia?

Answer 6

• auditory hallucinations
• use of clang association
• delusion of perception
• delusion of persecution
• constantly waving arms

Question 7

What are some examples of negative symptoms?

Answer 7

lack of motivation and flat affect

Question 8

A client hears voices saying, “kill your doctor,” what action should the nurse take first?

Answer 8

initiate one-to-one observation of the client

Question 9

what should be included in the patient teaching for a client prescribed donepezil for Alzheimer’s?

Answer 9

take this medication at the end of the day before bed

Question 10

what are some findings that can be expected in a client with delirium related to an acute UTI?

Answer 10

• family report of personality changes
• hallucinations
• restlessness

Question 11

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal, what are some findings that the nurse may expect?

Answer 11

• fine tremors of both hands
• vomiting
• restlessness

Question 12

what is the priority intervention for a client who is experiencing benzodiazepine withdrawal?

Answer 12

implement seizure precautions

Question 13

what is preferred for osteoarthritis pain relief for a patient taking lithium therapy?

Answer 13

aspirin instead of ibuprofen (decreases risk for lithium toxicity)

Question 14

What are some manifestations of early lithium toxicity?

Answer 14

• polyuria
• muscle weakness

Question 15

A client who has had their last drink at 1100, when are they most likely to experience withdrawal?

Answer 15

1500- 2300 (withdrawal symptoms are most likely to appear 4-12 hours within cessation)

Question 16

A client admitted to the inpatient detoxification program for alcohol withdrawal approaches the nurse complaining of nausea and feeling shaky. The nurse notices that the client has hand tremors and appears diaphoretic. Which of these nursing interventions is a priority?

Answer 16

Administer prn benzodiazepine that was ordered for management of withdrawal symptoms.

Question 17

A client who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job states to the nurse, “I don’t have a problem with alcohol. My boss is a jerk! I haven’t missed any more days than my coworkers.” What is the nurse’s best response?

Answer 17

“You are here because your drinking was interfering with your work.”

Question 18

Which medication is the physician most likely to order for a client experiencing alcohol withdrawal syndrome?

Answer 18

chlordiazepoxide

Question 19

Symptoms of alcohol withdrawal include:

Answer 19

Diaphoresis, nausea and vomiting, and tremors.

Question 20

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions for which of the following medications to promote long-term abstinence from alcohol?

Answer 20

disulfiram, naltrexone, and acamprosate

Question 21

A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority?

Answer 21

implement seizure precautions

Question 22

A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?

Answer 22

fine tremors, vomiting, restlessness

Question 23

A home health nurse is making a visit to a client who has Alzheimer’s disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury?

Answer 23

install extra locks at the top of exit doors

Question 24

A nurse is completing an admission for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms

Answer 24

• auditory hallucinations
• use of clang association
• constantly waving arms
• delusion of persecution

Question 25

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following medication?

Answer 25

risperidone (atypical antipsychotics)

Question 26

A charge nurse is discussing manifestation of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first-generation antipsychotics

Answer 26

Auditory hallucinations, delusions of grandeur, and severe agitation

Question 27

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)?

Answer 27

drooling, involuntary arm movements, and continual pacing

Question 28

what may hallucinations, diaphoresis, and agitation indicate in a client who took an initial dose of fluoxetine (SSRI) 4 hrs ago?

Answer 28

serotonin syndrome

Question 29

What is common for a client to experience following ECT?

Answer 29

confusion and disorientation

Question 30

What should the nurse provide following ECT until the client has a stable respiratory status?

Answer 30

oxygen

Question 31

Due to the risk for confusion after ECT, what intervention should the nurse implement?

Answer 31

reorient the client to their environment

Question 32

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome?

Answer 32

stop taking the herbal supplement while taking this med

Question 33

If a patient is taking selegilline, why should they notify the provider of drowsiness?

Answer 33

this may indicate a manifestation of serotonin syndrome

Question 34

Which brain structures are most associated with the drive for compulsive substance use?

Answer 34

prefrontal cortex, basal ganglia, and amygdala

Question 35

A CNS depressant such as a sedative works on which areas of the body?

Answer 35

muscles, brain, nerves, and heart

Question 36

A client is experiencing withdrawal symptoms from alcohol use. Which of the following medications is most appropriate?

Answer 36

diazepam

Question 37

Withdrawal from this substance requires a quiet atmosphere, sleep, food, and antidepressants. Name the substance.

Answer 37

stimulants

Question 38

what is avolition?

Answer 38

lack of motivation (this may present as poor hygiene)

Question 39

what is anergia?

Answer 39

lack of energy

Question 40

what is anhedonia?

Answer 40

lack of pleasure

Question 41

what is alogia?

Answer 41

lack of thoughts/speech

Question 42

What medications may cause tardive dyskinesia, EPS, dystonia, NMS?

Answer 42

typical antipsychotics (haloperidol)

Question 43

What type of medications may cause increase metabolic syndrome symptoms?

Answer 43

atypical antipsychotics

Question 44

What are tyramine foods?

Answer 44

Raisin, smoked meats, pickles, chocolate cake, aged cheese

Question 45

What may be found in schizoaffective disorder?

Answer 45

Hallucinations and depression

Question 46

What intervention may be used for someone who has hallucinations?

Answer 46

distract them with a TV

Question 47

What is a side effect of inhalant intoxication?

Answer 47

slurred speech

Question 48

what is the purpose of the MMSE?

Answer 48

assess for neurocognitive disorders