Exams Flashcards
The nurse states, “I notice you become very anxious when we talk about your drug use.” Which of the following therapeutic communication is being used?
Making observations
A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?
self-destructive behavior despite alternative interventions
A client tells the nurse, “I experience stress on a regular basis. Why do I feel this way?” Which is the nurse’s most appropriate response?
“Your reactions to past experiences influence your current feelings.”
Which is the first step the nurse should take when using therapeutic communication?
to clarify personal attitudes values and beliefs
An aging client with chronic schizophrenia takes an antipsychotic and propranolol, a beta-adrenergic blocking agent, for hypertension. Given the combined side effects of these drugs, which client teaching should the nurse provide?
rise slowly when you change position from lying to sitting or sitting to standing
Ortho hypo
- The nurse states, “I notice you become very anxious when we talk about your drug use.” Which of the following therapeutic communication is being used?
making observations
A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?
self-destructive behavior despite alternative
interventions
A client tells the nurse, “I experience stress on a regular basis. Why do I feel this way?” Which is the nurse’s most appropriate response?
“Your reactions to past experiences influence your current feelings.”
The patient is telling the nurse that she is going to divorce her cheating husband. The nurse states, “ I don’t blame you, you deserve better than that”. This is an example of which type of communication?
giving advice
A nurse is reviewing the medical record of a client who has schizophrenia and is receiving olanzapine. Which of the following findings should the nurse identify as an adverse effect of olanzapine?
Weight gain of 3lb in 2 weeks
A client tells the nurse, “I have nothing left to enjoy in life. My children are grown and married.” The nurse replies, “I’m sure you are looking forward to having
Grandchildren.”
Which communication technique is the nurse using?
using denial
A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). About which potentially fatal side effect will the nurse teach the client?
Agranulocytosis
A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal
and ethical obligations?
The nurse refuses to give any information to the caller, citing rules of confidentiality.
Your patient is depressed. She has a sudden change of mood and becomes more interactive and bright. She begins talking about giving some of her possessions to friends and family. What should the nurse’s response be?
ask the patient if she has any thoughts about suicide
The client understands dietary restrictions when taking MAOIs when the client makes which of the following statements?
“I should avoid foods that are high in the amino acid tyramine such as aged cheese, meats, and chocolate because this drug causes the level of tyramine to go up to dangerous levels.”
Which information suggests caution is necessary in prescribing a benzodiazepine to an anxious client?
the client has a hx of alcohol dependence
**sedation
A nurse is providing education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety?
awareness of factors creating stress
According to a mental health diagnosis, in which axis would borderline personality disorder be located?
Axis II
Which client statement alerts the nurse that the client may be responding maladaptively to stress?
avoiding contact w others help me cope
A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 pounds since then. Which is the most appropriate nursing response?
“Weight gain is a common, but troubling side effect. Let’s talk about some strategies for safely improving your nutrition and exercise habits.”
When the nurse asks that patient to describe their problem, what is the nurse actually assessing?
perception of the problem
A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse understands the client’s response is associated with which neurotransmitter?
norepi
Which statement reflects the therapeutic communication technique the nurse should use when communicating with a client who is experiencing auditory hallucinations?
I understand that the voice seem real to you, but i do not hear any voices
A client diagnosed with major depressive disorder asks, “What part of my brain controls my emotions?” Which nursing response is best?
The limbic system
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?
you must be very upset about something
In which axis would you find that a patient has no support system?
Axis IV
When a patient is physically being moved by the mental health professionals, this is considered to be which type of restraint?
Physical restraint
When used in combination with anxiolytic medication, alcohol leads to ____ effects and caffeine leads to ____ effects.
increase; decrease
A client was admitted with a single episode of major depression that was moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg PO qd. The nurse’s discharge teaching should include all of the following except:
u can discontinue prozac (ssri) when u feel better
answer: avoid tyramine foods: beer, beans, processed meats, and red wine
When caring for a Schizophrenic who is receiving Risperdal (risperidone), the nurse is aware that this medication is likely to have which possible long-term effect on the client?
A potential for gynecomastia
** Rise a pair
An instructor is teaching nursing students about neurotransmitters. Which term best explains the process by which neurotransmitters released into the synaptic cleft return to the presynaptic neuron?
Reuptake
While reviewing laboratory results of a newly admitted client, the nurse discovers that the client’s thyroid stimulating hormone (TSH) levels are elevated. The nurse anticipates the client will exhibit which symptoms?
depression & fatigue
What is the most important nursing intervention when restraining an aggressive client?
Check correct application if the restraints
. A patient asks the nurse why he has to attend therapy and not just take his prescribed antidepressant medication for his depression. Which is the most therapeutic response?
Stating, “Medications help your brain function better, but the therapy helps you achieve lasting behavior change.”
A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
“I see you have some grooming today”
A nurse is reviewing the medical histories of four clients. Which of the following clients may develop extrapyramidal symptoms (EPS) from medication therapy?
A client who has schizophrenia and is taking
antipsychotic medication
A school nurse is assessing a female high-school student who is overly concerned about her appearance. The client’s mother states, “That’s not something to be stressed about!” Which response by the nurse is best?
Stress can be psychological. A threat to self-esteem may result in high stress levels.”
A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the first priority?
Assign a staff member stay with the client at all times
A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?
The client states “my heart is pounding out of my chest”
**anxiety
When is the short-term use of restraints permitted?
Only when the client is imminently aggressive and dangerous to themselves or others.
Which part of the nervous system should the nurse identify as playing a major role during stressful situations?
Sympathetic nervous system
**StreSS
The patient has a lithium level of 1.2 mEq/L. Which intervention is appropriate?
No intervention is necessary at this time
normal is: 0.6-1.2
A physician prescribes an additional medication for a client taking an antipsychotic agent. The medication is to be administered “prn for EPS.” Which is the most appropriate nursing assessment to determine when to give this medication?
When the client exhibits tremors and a shuffling gait
A client with depression and substance abuse has an interrupted sleep pattern. She demands that her psychiatrist prescribe her a sedative. Which teaching should the nurse provide about the rationale for the use of
nonpharmacological interventions instead?
“Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as one builds up tolerance to them.”
As part of discharge teaching, which guideline regarding lithium therapy will the nurse plan to include?
- Avoid excessive use of beverages containing caffeine.
- Maintain a consistent sodium intake.
- Consume at least 2,500 to 3,000 mL of fluid per day. 4. All of the above
Which medication is most likely to be prescribed for the extrapyramidal side effects of antipsychotic
medications?
Benztropine (Cogentin)
The nurse’s patient states “it has been so long since I have seen my family”. How can the nurse use the therapeutic communication technique of RESTATING?
“you say you haven’t seen your family in a while”
Education for the client who is taking MAOI’s should include which of the following?
tyramine-restricted diet, prohibitive concurrent use of over the counter medications without physician notification.
A nurse administers 100 percent oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?
To prevent anoxia due to medication-induced paralysis of respiratory muscles
A client with depression asks, “why are they checking my thyroid function when I clearly have depression, and I’m not overweight?” Which of these is an accurate response?
Thyroid hormone replacement is a first-line treatment for most clients with depression.
- An underactive thyroid gland can manifest as depression.
What signs and symptoms must patients with Major
Depressive Disorder have to report in order to be given that diagnosis?
Sleep disturbances, lack of interest in activities,
appetite changes, psychomotor retardation
SIGECAPS
What is a true statement regarding suicide contracts?
“There’s no demonstrated benefit of no-suicide
contracts, though they’re not believed to be harmful.”
When planning care for a depressed client, which correctly written outcome should be a nurse’s first priority?
The client will remain safe during hospital stay
What is a true statement regarding ECT therapy?
It effectively treats severe depression
What statement is true regarding SSRI medications designed to treat symptoms of depression?
They have an increase risk for suicidal thoughts
In order to be diagnosed with major depressive disorder, what time frame criteria has to be met?
2 weeks “2 blue weeks”
A client diagnosed with Schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should the nurse expect a physician to order to address this type of symptom?
Risperidone (Risperdal)
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
The client responds to questions with disorganized speech
DIGFAST
.Which medication should the nurse anticipate for a client who has a history of a complicated withdrawal of benzodiazepine?
Chlordiazepoxide (Librium) and phenytoin
Dilantin
A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within 30 minutes period. Which Is the best rationale for assessing this client for substance addiction?
Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require INCREASED doses to achieve effective pain control.
A client with a history of heavy alcohol use us brought to an emergency department (ED) by family members who states that the client has had nothing to drink in the last 48 hours. When the nurse reports to the ED physician, which client symptoms should be the nurse’s first priority
bp 180/100
A client is diagnosed with schizophrenia spectrum disorder is prescribed clozapine. Which client symptoms related to the side effect of this medication should prompt a nurse to intervene immediately?
Sore throat, fever, and malaise
** agranulocytosis-> risk of infection
Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnoses with schizophrenia spectrum disorder?
Being reliable, honest, and consistent during
interactions
When planning care for a depressed client, which correctly written outcome should be a nurse’s first priority?
The client will remain safe during hospital stay
A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “should I seek psychiatric help for my mother”. Which is an appropriate nursing response?
“Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”
Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse’s coworker observes this action but does nothing for fear of retaliation. What is the ethical interpretation of the coworker’s lack of involvement?
Taking no action is still considered an unethical action by the coworker.
Which client statement indicates a knowledge deficit related to a substance use disorder?
“Marijuana is like smoking cigarettes. Everyone
does it. It’s essentially harmless.”
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, “I should have died because I am totally worthless”. Which of the following responses should the nurse make?
“You’ve been feeling that your life has no meaning.”
Which information suggests caution is necessary in prescribing a benzodiazepine to an anxious client?
The client has a history of alcohol dependence.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD), which of the following actions should the nurse take first?
Identify precipitating factors for ritualistic behaviors.
A highly agitated client paces the unit and sates, “ I could buy and sell this place” the client’s mood fluctuates from fits to laughter to outburst of anger. Which is the most accurate documentation of the client’s behavior?
“Agitated and pacing. Exhibiting grandiosity. Mood labile.”
What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode?
Depression can generate somatic symptoms that can
mask actual physical disorders.
A nurse is caring for a client who is schizophrenia and tells the nurse, “they lie about me all the time and they are trying to poison my food” which of the following statements should the nurse make?
“You seem to be having very frightening thoughts.”
A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10mg HS. Which client behavior would warrant the nurse to administer benztropine?
Restlessness and muscle rigidity
A client diagnosed with bipolar 1 disorder is exhibiting severe maniac behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response?
Zyprexa calms hyperactivity until the Eskalith takes effect.”
A nurse is reviewing a medical record of a client who has schizophrenia and is receiving olanzapine, which if the following findings should the nurse identify as an adverse effect of olanzapine?
Weight gain of 3 lbs in 2 weeks
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?
command hallucinations
What is a true statement regarding ECT therapy?
Patient’s report decreased short-term memory as a side effect of the tx.
The client states “I get into trouble because I respond violently without thinking. That usually gets me in a mess” which nursing reply is most therapeutic?
“Let’s explore methods to help you stop and think before taking action.”
Which statement should the nurse identify as correct regarding a client’s right to refuse treatment?
Professionals can overridetreatment refusal if the client is actively suicidal or homicidal
A school nurse is talking with a 13-year-old female at her annual health screening visit. Which of the following comments made by the adolescent should be the nurse’s priority to address?
“None of the kids at this school like me, and I don’t like them either.”
A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to access? Select all that applies
1.Feelings of guilt that precipitate social isolation 2.Aggressive behavior that affects job
performance
3.Relationship problems
4.High levels of anxiety
A patient treated for symptoms of PTSD following a shotting incident at a local elementary school reports, “I feel like there’s no reason to go on living when so many others died” which is the most appropriate response by the nurse now?
“Are you having thoughts of hurting or killing yourself?”
A military veteran who recently returned for active duty in the Middle Eastern country and suffers for PTSD states he will not allow that laboratory technician who is Iranian to draw his blood. The patient states, “he will probably use a
contaminated needle on me” which of these is the most appropriate nursing response by the nurse?
“Let me see if I can arrange for a different technician to draw your blood.”
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for this client?
A private room in a quite location on the unit
A client began taking lithium for treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 pounds since then. Which is the most appropriate nursing response?
“Weight gain is a common, but troubling side effect. Let’s talk about some strategies for safely improving your nutrition and exercise habits.
A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. “the beatings have been getting worse and I’m afraid next time he will kill me” which is the appropriate nursing response?
“Let’s talk about your options so that you don’t have to go home.”
A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate?
Discontinue the fluoxetine and rethink the client’s diagnosis.
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should then nurse manager make?
I can review the assignments and arrange for a female nurse to care for you
A nurse is planning care for a client diagnosed with bipolar disorder, manic episode. In which order should the nurse prioritize the client outcomes in the exhibit?
Choices: 1. Maintain nutritional status, 2. Interacts appropriately with peers, 3. Remain free from injury, 4. Sleeps 6 to 8 hours a night ANSWER: 3. remain free of injury 1. maintain nutritional status 4. sleep 6-8 hrs a night 2. interacts appropriately with peers
A nurse reports an incidence of suspected child abuse. One of the parents of the child becomes upsets and demands to know the reason for the nurse’s action. Which of the following responses by the nurse is appropriate?
“as a nurse, i’m required by law to report suspected child abuse.”
A client diagnosed with schizophrenia spectrum disorder
tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?
Risk for violence: directed toward others
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements.
“In my dreams, all I can see are the wounded reaching out and trying to grab me.”
A cab driver stuck in traffic becomes lightheaded, tremulous, diaphoretic and dyspneic because his boss told him that if he didn’t make it back on time to the station he would be fired. A workup in the emergency department reveals no pathology. Which medical diagnosis should the nurse suspect and what nursing diagnosis should be then nurse’s first priority?
Panic disorder and a nursing diagnoses of anxiety
The client understands dietary restrictions when taking MAOIs when the client makes which of the following statements?
“I should avoid foods that are high in the amino acid tyramine such as aged cheese, meats, and chocolate because this drug causes the level of tyramine to go up to dangerous levels.”
A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy
(ECT). The client’s spouse asks the nurse about the possible side effects of ECT. Which of the following responses should the nurse make?
The main side effects are temporary and may include some mild confusion, a headache, and short term memory loss
A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy
(ECT). The client’s spouse asks the nurse about the possible side effects of ECT. Which of the following responses should the nurse make?
The main side effects are temporary and may include some mild confusion, a headache, and short term memory loss
Which of the following medications could be used to decrease aggression by dampening excessive noradrenergic activity ?
Beta blockers (end in -lol)
Sammy is diagnosed with a trauma disorder and is being treated at an inpatient psychiatric unit, what nursing short term goal is most appropriate for Sammy?
Sammy demonstrates three relaxation
techniques upon discharge.
A kindergarten student is frequently violent towards other children. The school nurse notices bruises and burns on the child’s face and arms. Which are other symptoms should indicate to the nurse that the child may have been physically abused?
The child shrinks at the approach of adults.
Sandy, a rape survivor, is being treated for PTSD, which of these statements are good indication sandy is beginning to recover from PTSD?
“This traumatic event immobilized me for awhile, but I have found imagery helpful in reducing my anxiety.”
An adult client assaults another client and is placed in restraints. Which client statement alerts the nurse that a further assessment is necessary?
My fingers are tingly.”
A nurse is caring for four clients. Which client does the
nurse identify is least prone to developing problems with anger or aggression?
An adolescent raised by Scandinavian immigrant parents
The client states, “ I get into trouble because I respond violently without thinking that usually gets me into a mess.” Which nursing reply is most therapeutic
“Let’s explore methods to help you stop and think before taking action.”
When planning care for a client diagnosed with BPD, which self-harm behavior should the nurse expect the client to exhibit?
The use of suicidal gestures to evoke a rescue response from others
A client’s altered body image is evidenced by claims of “feeling fat” even though the clients emaciated. Which is the appropriate outcome criterion for this client’s problem?
The client will perceive an ideal body weight and shape as normal
A client diagnosed with NCD due to Alzheimer’s disease
can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalization. The nurse recognizes that these symptoms indicate which stage of illness?
Late stage
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
Affective flattening
A nurse in the emergency department is implementing a plan of care for an older adult who is experiencing delirium tremens. Which of the following actions should the nurse take first?
Raise the bed side rails (risk for falls)
