Exam 3 Study Guide: Q (part 2)

Question 1

The nurse is working with a client diagnosed with Somatic Symptom Disorder.
What predominant symptoms should the nurse expect to assess?

Answer 1

Disproportionate and persistent thoughts about the seriousness of one’s symptoms

Question 2

The nurse is working with a client who is being admitted to the psychiatric–mental health unit. The client was missing for two weeks was unaware that any time had passed after being found wandering the streets nowhere near his house.
Which of the following dissociative disorders has this client experienced?

Answer 2

Fugue

o A person with dissociative fugue wanders, usually far from home and for days, perhaps even weeks or months, at a time. During this period, clients completely forget their past life and associations; but unlike people with amnesia, they are unaware of having forgotten anything.

Question 3

A client with suspected factitious disorder presents to the clinic with severe back pain rated 9/10.
The nurse understands that:

Answer 3

o Treat the client’s pain as real until determined otherwise- The client’s pain must be treated as real unless it is known to be false.

Question 4

The nurse is caring for a patient diagnosed with Conversion Disorder.
Which statement made by the nurse is most therapeutic for this patient?

Answer 4

o “I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties”

This statement encourages the patient to verbalize fears and anxieties. Verbalizing these feelings will help the patient identify physical symptoms as a coping mechanism that is used in times of extreme stress.

Question 5

Chuck came into his parents’ home and witnessed his parent’s murder scene. The police and forensics arrived at this site and cordoned off the crime scene. Chuck was taken home by friends where he later reported blindness. A full examination was conducted at the hospital, where no physical reason for the blindness was found.
The unlicensed assistive personnel asked the RN, what is the diagnosis?

Answer 5

o Conversion disorder

This patient is presenting with conversion disorder, a medical condition that is psychologically driven that has no basis for the symptoms. The client will lose function in a body system. This happens when the client has experienced a traumatic event.

Question 6

The nurse would express concern to the prescriber if the client has which of the following symptoms?

Answer 6

command hallucinations

Question 7

when working with a client that is non-compliant in treatment, what is the nurse’s first intervention

Answer 7

address the reasons for non-compliance

Question 8

which statement indicates to the nurse that a client is experiencing a delusion

Answer 8

the government is watching everything I do

Question 9

the nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations.
which is the nurse’s best reply

Answer 9

ask him what the voices are saying to him

Question 10

· A client who has been taking chlorpromazine (Thorazine) for several months presents in the emergency department with EPS of restlessness, drooling, and tremors.
What medication will the nurse expect the physician to order?

Answer 10

benztropine (cogentin)

Question 11

a nurse is caring for a client prescribed haloperidol for his chronic paranoid schizophrenia.
which complications should the nurse monitor?

Answer 11

chewing motion with the mouth

Question 12

a patient believes the FBI is out to get them,
what are they experiencing?
another patient says they can see the FBI in the corner of the room,
what are they experiencing?

Answer 12

1. delusions
2. hallucinations

Question 13

Positive or Negative symptom of schizophrenia

1. hallucination
2. delusion
3. alogia or poverty of speech
4. catatonia
5. flat affect
6. paranoia
7. avolition or loss of motivation

Answer 13

1. hallucination - positive
2. delusion - positive
3. alogia or poverty of speech - negative
4. catatonia - positive
5. flat affect - negative
6. paranoia - positive
7. avolition or loss of motivation - negative

Question 14

A client is brought to the emergency department. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dL. Among the physician’s orders is thiamine. Which is the rationale for this intervention?

Answer 14

to prevent wernicke’s encephalopathy

most serious form of thiamine deficiency in clients diagnosed with alcoholism

Question 15

who determines the length of time a psychiatric facility an hold a client?

Answer 15

state law

can override treatment refusal if client is actively suicidal or homicidal

Question 16

A client is diagnosed with Schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer Benztropine?

Answer 16

restlessness and muscle rigidity

Question 17

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the ED experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse recognizes that the client’s symptoms indicate which of the following?

Answer 17

a reaction to disulfiram (antabuse)

Question 18

The nurse is caring for a client with phase III of schizophrenia. The nurse anticipates the patient will be exhibiting which signs or symptom the disorder?

Answer 18

active positive symptoms

Question 19

During a nurse–client interaction, an adolescent client with a major depressive disorder stated, “I was on the basketball team at school, but I don’t have the energy to play so I quit.” The client is describing:

Answer 19

anergia

Question 20

· The charge nurse on an inpatient psychiatric floor is teaching a floor nurse about signs and symptoms of alcohol withdrawal. The charge nurse knows the floor nurse demonstrates understanding when the floor nurse lists which of the following signs and symptoms? Select all that apply.

Answer 20

o vomiting
o tremors
o hallucinations

Question 21

· An inpatient client is newly diagnosed with anxiety disorder stemming from severe childhood sexual abuse. Which is the priority nursing intervention?

Answer 21

establish trust and rapport

Question 22

During an intake assessment, the nurse asks a client physiological and psychosocial questions. The client angrily responds, “I’m here for my heart problems, not for my head.” Which is the nurse’s best response?

Answer 22

psychological stress can affect medical conditions

Question 23

A nurse is collecting past history data on a patient with acute stress disorder (ASD). Which of the following behaviors would the nurse anticipate finding?

Answer 23

the patient expresses a sense of unreality concerning the traumatic event

Question 24

The nurse is administering risperidone to a client diagnosed with schizophrenia. The nurse anticipates the medication to have a therapeutic effect on which symptoms? Select all that apply.

Answer 24

o somatic delusions
o gustatory hallucinations
o clang associations

Question 25

The nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurse’s best reply?

Answer 25

ask him what the voices are saying to him

Question 26

A 22-year-old client with body dysmorphic disorder (BDD) tells the nurse that she plans to have a surgical procedure that will affect her appearance. The nurse understands that this plan is an effort to:

Answer 26

cure the imagined defect

Question 27

A nurse is providing care for a 30 year old client on a Medical/Surgical floor that has undergone 12 elective plastic surgeries. The nurse recognizes this client may be experiencing?

Answer 27

body dysmorphic disorder

Question 28

The nurse is assessing the client diagnosed with bipolar disorder. What assessment finding would cause the nurse to question possible substance abuse?

Answer 28

the client is disheveled and appears malnourished

Question 29

When working with a client that is non-compliant in treatment, what is the nurse’s first intervention?

Answer 29

address the reasons for non-compliance

Question 30

The nurse would express concern to the prescriber if the client has which of the following symptoms?

Answer 30

command hallucinations

Question 31

Amanda has been admitted to the hospital after being seen in an acute care walk-in clinic with blood in her urine. The admitting physician has ordered several invasive procedures: catheterization, blood work, and cystoscopy, among others. The physician does not know that Amanda has been taking anticoagulants to produce blood in her urine.
What data will the nurse elicit from Amanda that will confirm this diagnosis?

Answer 31

hx of multiple hospitalizations

Question 32

Chuck came into his parents’ home and witnessed his parent’s murder scene. The police and forensics arrived at this site and cordoned off the crime scene. Chuck was taken home by friends where he later reported blindness. A full examination was conducted at the hospital, where no physical reason for the blindness was found. The unlicensed assistive personnel asked the RN, what is the diagnosis?

Answer 32

conversion disorder

Question 33

The client is experiencing an episode of acute anxiety. The nurse will expect to observe which common coping behaviors?

Answer 33

social withdrawal

Question 34

Which statement indicates to the nurse that a client is experiencing a delusion?

Answer 34

the government is watching everything i do

Question 35

A 21 year old client diagnosed with dissociative identity disorder, presents in the emergency department (ED) after attempting suicide. Which data obtained during the client’s health history would support the current diagnosis?

Answer 35

sexual abuse by biological parent during childhood

Question 36

A nurse is working with a client that states being in public places causes them debilitating anxiety and even panic. Which therapies will the nurse provide education on? SATA.

Answer 36

o flooding
o systematic desensitization
o cognitive behavioral therapy (CBT)
o thought stopping

Question 37

The nurse is providing education to a client diagnosed with anxiety. Which statement by the client indicates that teaching has been effective?

Answer 37

practicing yoga or meditation may help reduce my anxiety

Question 38

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the past 24 hours. Which client symptom should the nurse immediately report to the ED physician?

Answer 38

blood pressure of 180/100 mmHg

Question 39

A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following immediate interventions should the nurse identify as the priority?

Answer 39

providing for adequate hydration, nutrition, an rest

Question 40

How would the nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?

Answer 40

depersonalization is commonly seen in panic disorder and absent in GAD

Question 41

A nurse is caring for a client prescribed haloperidol for his chronic paranoid schizophrenia. Which complications should the nurse monitor?

Answer 41

chewing motion with the mouth

Question 42

Amanda has been admitted to the hospital after being seen in an acute care walk-in clinic with blood in her urine. The admitting physician has ordered several invasive procedures: catheterization, blood work, and cystoscopy, among others. The physician does not know that Amanda has been taking anticoagulants to produce blood in her urine. The nurse is interviewing Amanda on her history. Which statement is most appropriate?

Answer 42

are you able to tell me about the onset and duration of your symptoms

Question 43

A client taking Phenelzine has a blood pressure of 210/119, a HR of 104 bpm, and diaphoresis. The nurse discovers the client has recently taken over the counter medication for allergies and a cold. The nurse recognizes this client is experiencing:

Answer 43

hypertensive crisis:

clients on MAOI should be told not to take any OTC medications or foods rich in tyramine prior to consulting their physician

Question 44

A nurse is assessing a client who has hypochondriasis (illness anxiety disorder). Which of the following findings should the nurse expect?

Answer 44

constant worry about undiagnosed illness

Question 45

The nurse assigns Ineffective Coping as a nursing diagnoses for a client diagnosed with substance abuse. Which intervention does the nurse use to assist the patient to gain adaptive responses to stress?

Answer 45

spend time with the client and establish a trusting relationship

Question 46

The nurse is caring for a client who has been diagnosed with dissociative disorder. The nurse knows that an appropriate intervention to promote effective role performance is to:

Answer 46

include family members in therapy

Question 47

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intent to leave the hospital. What information should the nurse recognize as having an impact on the treatment team’s next action?

Answer 47

state law determines the length of time a psychiatric facility can hold a client

Question 48

Which statement should the nurse identify as correct regarding a client’s right to refuse treatment?

Answer 48

professionals can override treatment refusal through court approval if the client is actively suicidal or homicidal

Question 49

When an individual’s stress response is sustained over a long period, the nurse anticipates which physiological effect?

Answer 49

decreased resistance to disease

Question 50

Which client statement alerts the nurse that the client may be maladaptively responding to stress?

Answer 50

avoiding contact with others helps me cope

Question 51

A male client with a recent diagnosis of depression is worried that medication will cause a lack of sexual interest. The nurse will anticipate the client being prescribed which psychotropic medication?

Answer 51

buproprion

Question 52

An 18-year-old client who joined the military shortly after graduating from high school is admitted to the mental health unit for depression and suicidal ideation. He tells the nurse the military is not what he expected and he wants to go home. The nurse observes a variance in affect between his interaction with peers and staff. The nurse suspects:

Answer 52

malingering

Question 53

During a nurse–client interaction, an adolescent client with a major depressive disorder stated, “I was on the swim team at school, but I don’t enjoy swimming anymore so I quit.” The client is describing:

Answer 53

anhedonia

Question 54

A client with bipolar disorder commands another client, “Change the television channel. Get me something to drink…,” and so forth. The nurse wants to interrupt this behavior without entering into a power struggle. Select the nurse’s best approach:

Answer 54

distraction:

“let’s go to the dining room for a snack”

Question 55

A nurse is conducting a mental status exam. The nurse will assess for which of the following? (Select all that apply)

Answer 55

o thought content
o grooming
o behavior
o eye contact

Question 56

A client with a somatic symptom disorder presents to the community clinic describing abdominal pain, refuses to complete informational forms, and dismisses the nurse’s assessment attempts while demanding to be seen immediately by a doctor. Which approach would be best for the nurse to use when assessing this client?

Answer 56

avoid personalizing the behavior of the client

Question 57

A client is experiencing a severe panic attack. Which nursing intervention would meet this client’s immediate need?

Answer 57

stay with the client and offer reassurance of safety

Question 58

The nurse assesses a client who exhibits a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement indicates the nurse understands the characteristics of positive and negative symptoms of schizophrenia?

Answer 58

paranoia, neologisms, and echolalia are positive symptoms

Question 59

In assessing a potential client with Schizophrenia, which phase is research currently focused on in order to identify at-risk individuals as early as possible?

Answer 59

the premorbid phase

Question 60

The nurse working on an inpatient psychiatric unit is caring for a patient with schizophrenia and substance abuse disorder. The nurse administers the patient’s medications as ordered. Which patient response will the nurse report immediately to the health care provider?

Answer 60

temp of 102.1*F

Question 61

Warren’s college roommate actively resists going out with friends whenever they invite him. He says he can’t stand to be around other people and confides to Warren “They wouldn’t like me anyway.” Which disorder is Warren’s roommate likely suffering from?

Answer 61

social anxiety disorder (social phobia)

Question 62

A client diagnosed with Somatic Symptom Disorder is most likely to exhibit which personality disorder characteristics?

Answer 62

expresses heightened emotionality, anxiety, and strong dependency needs

Question 63

To intervene effectively with clients with somatic symptom disorders, it is essential that the nurse:

Answer 63

recognize and understand the client’s somatizations as demonstrating an inability to cope

Question 64

A client comes in with descriptions of stress and identifies a life changing event. They explain that ever since the event, they have had worsening moods, increased impatience, and claims they never feel at peace. The client’s response can be identified as a form of?

Answer 64

maladaptation

Question 65

A nurse is educating an adolescent and their parents about the new prescription for an SSRI. What will the nurse include in the teaching?

Answer 65

while on this medication you are at an increased risk of suicide

Question 66

Wernicke’s encephalopathy results from heavy chronic alcohol use and ______ deficiency

Answer 66

thiamine or vitamin B1

Question 67

A newly admitted patient diagnosed with OCD, spends 1-hour packing and unpacking, folding and refolding personal belongings. What is the most likely reason for this behavior?

Answer 67

it relieves anxiety

Question 68

A client diagnosed with obsessive-compulsive disorder spends 45 minutes washing their hands and completing ritualistic tasks. Which nursing intervention would best address this client’s problem?

Answer 68

Discuss the anxiety
o provoking triggers that precipitate the ritualistic behaviors.

Discussing triggers will enable the client to address and deal with obsessions and compulsions. Distracting the client will increase the anxiety. The client should only be stopped from completing the behaviors by trained professionals therapeutically.

Question 69

A nurse working in an emergency department is caring for a patient who has alprazolam toxicity. Which of the following actions is the nurse’s priority?

Answer 69

identify the patient’s level of orientation

o when taking the nursing process approach to client care, the initial step is assessment.
o identifying the client’s level of orientation is the priority action

Question 70

A nursing instructor is teaching about specific phobias. Which student statement indicates that learning has occurred?

Answer 70

“these clients have overwhelming symptoms of panic when exposed to the phobia stimulus”

o phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response