M2 Flashcards
1
Q
The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics:
a. Remain in the system longer
b. Act more quickly to reduce delusions
c. Produce fewer extrapyramidal effects
d. Are risk free for neuroleptic malignant syndrome (NMS)
A
C
(Atypical antipsychotics produce less D2 blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quickly to reduce delusions. The atypicals are not risk free for NMS.)
2
Q
The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a:
a. 30 mm Hg decrease in blood pressure reading
b. Respiratory rate of 24 respirations per minute
c. Temperature reading of 104 F
d. Pulse rate of 70 beats per minute
A
C
(Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate.)
3
Q
A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms?
a. Decreased dopamine at receptor sites
b. Blockade of histamine
c. Cholinergic blockade
d. Adrenergic blocking
A
C
(Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation.)
4
Q
Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)?
a. Grimacing and lip smacking
b. Falling asleep in the chair and refusing to eat lunch
c. Experiencing muscle rigidity and tremors
d. Having excessive salivation and drooling
A
A
(TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine.)
5
Q
When the nurse realizes that a patient diagnosed with schizophrenia is not taking the prescribed oral haloperidol (Haldol), which intervention would promote medication compliance?
a. Instructing the patient to have friends monitor his medications
b. Beginning administration of haloperidol (Haldol) decanoate
c. Writing instructions in detail for the patient to follow
d. Changing haloperidol to an atypical antipsychotic
A
B
(Haloperidol decanoate is a depot medication, given intramuscularly every 2 to 4 weeks. It is unknown whether the patient has a support system. The patient probably received education, including written instructions prior to discharge. Changing to another classification of medication would not necessarily improve compliance.)
6
Q
When asked how tricyclic antidepressants affect neurotransmitter activity, the nurse should respond that they:
a. Decrease available dopamine.
b. Increase availability of norepinephrine and serotonin.
c. Make available increased amounts of monoamine oxidase.
d. Increase the effects of the chemical gamma-aminobutyric acid.
A
B
(Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of norepinephrine and serotonin available. Decreasing dopamine is the action of typical antipsychotic medication. Increasing monoamine oxidase is not the action of tricyclics. Benzodiazepines, not tricyclics, increase the effects of GABA.)
7
Q
A severely depressed patient has been prescribed clomipramine (Anafranil). For which medication side effects should the patient be monitored?
a. Excess salivation and drooling
b. Muscle rigidity and restlessness
c. Polyuria and coarse hand tremors
d. Orthostatic hypotension and constipation
A
D
(Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces constipation. Mild tremors and urinary retention may occur. Drooling and excessive salvation may occur with SSRIs. Muscle rigidity and restlessness may occur with antipsychotics.)
8
Q
Which of these statements made by a patient taking the MAOI phenelzine (Nardil) would warrant further instruction?
a. I often forget to wear sunscreen when I go outside.
b. I need to restrict the amount of sodium in my diet.
c. I should not use over-the-counter cold medications.
d. I usually order liver and onions when my wife and I eat out.
A
D
(MAOIs require patients to observe a tyramine-free diet to prevent hypertensive crisis. Liver is a food that contains large amounts of tyramine. The remaining options have no relevance for MAOI therapy.)
9
Q
Which patient complaint should receive priority from a patient who is taking the MAOI tranylcypromine (Parnate)?
a. I haven’t had a bowel movement in 2 days.
b. Will you take my temperature? I feel too warm.
c. I get a headache when I drank several cups of coffee.
d. My legs get stiff when I sit in the chair for any length of time.
A
C
(Hypertensive crisis may occur if a patient taking a MAOI ingests certain food containing tyramine or drugs that cause blood pressure (BP) elevation. Headache is a warning sign of hypertensive crisis. The nurse should assess BP and inquire about other symptoms of hypertensive crisis. Stiffness is not related to MAOI therapy. Elevated temperature is not an initial sign of hypertensive crisis. Constipation is not a sign of hypertensive crisis.)
10
Q
Sertraline (Zoloft) has been prescribed for a patient with symptoms of a major depression. Which factor was probably most important in the physicians decision to use an SSRI?
a. Good side-effect profile
b. Less expense for the patient
c. Increase in medication compliance
d. Rapid rate of absorption from the GI tract
A
A
(Compared to other antidepressant medication groups, SSRIs have the best side-effect profile. SSRIs are more costly. No studies have shown that SSRIs result in better compliance. These drugs are absorbed slowly from the GI tract.)
11
Q
Which statement made by a patient who will be maintained on lithium following discharge will require further instruction by the nurse?
a. I will have my blood work done regularly.
b. When I get home, I may go on a salt-free diet.
c. I have learned not to restrict my intake of water.
d. I understand some people gain weight on lithium.
A
B
(This statement shows that the patient does not understand the relationship between lithium and sodium. The patient must be taught that changing dietary salt intake will affect lithium levels. Adding salt can cause lower levels; reducing salt can result in toxicity. The remaining options reflect correct information regarding lithium therapy.)
12
Q
To educate a patient regarding what to expect following the administration of a benzodiazepine, the nurse must understand that benzodiazepines:
a. Have a rapid onset of peak action
b. Reduce availability of GABA
c. Generally diminish the activity of GABA
d. Interact with serotonin to increase availability
A
A
(Benzodiazepines do have a more rapid onset. There is no effect on the availability or function of GABA. Benzodiazepines do not diminish GABA activity; they enhance it.)
13
Q
A patient prescribed alprazolam (Xanax) for symptoms of anxiety shares with the nurse that, Im concerned about getting off this medication. Upon which fact will the nurse base the response to the patients concern?
a. Long elimination half-life will result in a manageable withdrawal treatment plan.
b. Rapid absorption and distribution to brain cells make withdrawal more difficult to manage.
c. Sensitivity of the mesencephalic reticular activating system makes addiction unlikely.
d. The combination of medication with an antidepressant often positively impacts withdrawal.
A
B
(In general, shorter-acting benzodiazepines are more difficult to taper and potentially cause more problems with withdrawal. The remaining options are neither true nor relevant.)
14
Q
Which patient outcomes would be most applicable for the patient who has been taking benzodiazepines? Patient will state:
a. That there are specific foods to avoid while on this medication
b. An understanding of how to increase medication dosage
c. That alcohol is a substance to avoid while on the medication
d. An understanding that he or she can return to work while on this medication
A
C
(Combining a benzodiazepine with alcohol or other CNS depressant is potentially fatal. No food restrictions exist. Dosage should not be changed without consultation with the physician. Patients may return to work unless experiencing sedation. In this case, they would be cautioned not to operate machinery.)
15
Q
Which person with mania is the least likely candidate to receive lithium? The patient who is:
a. Six weeks pregnant
b. Recovering from a hysterectomy
c. Taking hormone replacement therapy
d. Displaying symptoms of postpartum depression
A
A
(Lithium is contraindicated during pregnancy because of teratogenic effects. The remaining options would not be contraindicative to lithium therapy.)
16
Q
An individual with poststroke depression is receiving an SSRI. What is the rationale for giving the medication at breakfast and again at midday?
a. Prevent insomnia
b. Prevent toxic reactions
c. Decrease afternoon sleepiness
d. Give an opportunity to monitor behavior closely
A
A
(CNS stimulants may cause insomnia if given late in the day. Toxicity is a result of excessive medication in the system, not when it is administered. The drowsiness resulting from SSRI use would not be minimized if taken as described. There is no expectation that resulting behaviors will need to be so closely monitored.)
17
Q
A patient who has received lithium for 3 weeks to control acute mania has the following symptoms: coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion. The priority nursing action should be to:
a. Administer prn Cogentin to relieve the symptoms.
b. Provide reassurance that the symptoms are transient.
c. Obtain a stat lithium level; hold lithium pending results.
d. Assist the patient to decrease the sodium in their daily diet
A
C
(The symptoms the patient is experiencing are consistent with moderate lithium toxicity. The nurse should hold lithium, obtain a stat lithium level, and notify the physician. Cogentin is inappropriate; the symptoms are not EPS. The nurse may reassure the patient but cannot suggest that the symptoms will resolve over time. Minimizing salt would worsen lithium toxicity.)
18
Q
A patient with rapid cycling bipolar disorder is not responding well to lithium. The patient tells the nurse, It feels as though Ill never get well. I get better, and then I get worse. The reply that is based on knowledge of current therapy would be:
a. You’re feeling very discouraged aren’t you?
b. Its not all bad, is it? Sometimes you like being high.
c. Another drug, valproic acid, is proving effective for rapid cycling.
d. If your kidneys hold out, the lithium will eventually control the symptoms.
A
C
(Valproic acid is a first-line agent for the treatment of bipolar disorder. It is particularly effective with rapid cycling. The other options are not responsive to the question stem, which asks for knowledge of current therapy.)
19
Q
Which statement by a patient with generalized anxiety disorder for whom lorazepam (Ativan) is prescribed as needed (prn) suggests the patient understands the purpose of the medication?
a. I can talk with my therapist more easily after my medication takes effect.
b. I wonder if I will have to take this medication for the rest of my entire life.
c. I’m embarrassed and don’t want anyone to know I’m on this kind of medication.
d. I’m going to ask for my prn dose so I can sleep instead of worrying about my kids.
A
A
(The patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist. The remaining options show questions and inappropriate use of the medication.)
20
Q
A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks. He drools, has hand tremors, and walks with a shuffling gait. The nurse would correctly attribute these behaviors to:
a. Akinesia
b. Tardive dyskinesia
c. Pseudoparkinsonism
d. Neuroleptic malignant syndrome
A
C
(These are symptoms of pseudoparkinsonism associated with dopamine blockade. Tardive dyskinesia occurs after long-term therapy. The remaining options are not associated with the symptoms mentioned.)
21
Q
What intervention will the nurse request for a patient reporting gastrointestinal side effects related to valproate therapy?
a. Mild laxative
b. Low-fat diet
c. Oral antacid
d. Histamine-2 antagonist
A
D
(Indigestion, heartburn, and nausea are common side effects of valproate therapy. The administration of a histamine-2 antagonist such as famotidine (Pepcid) is sometimes helpful. The other options would have no impact on the complaint.)
22
Q
A patients serum lithium level is reported as 1.9 mEq/L. The nurse should immediately:
a. Restrict sodium and fluid intake.
b. Assess for signs and symptoms of toxicity.
c. Seek to have the patient transferred to ICU.
d. Notify the patients physician immediately.
A
B
(A serum lithium level this high suggests that the patient may be experiencing symptoms of lithium toxicity. Clinical assessment is essential to determine what, if any, signs and symptoms are present. After the clinical assessment has been made, the nurse can provide the physician with a complete picture. Restricting sodium and fluids would raise the serum level. Transferring may not be necessary and would require a physicians order.)
23
Q
To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic drug therapy, the nurse would look for improvement in:
a. Affective mobility
b. Positive symptoms
c. Self-care activities
d. Cognitive functioning
A
B
(Typical antipsychotic medications produce improvement in the positive symptoms of schizophrenia such as hallucinations and delusions. Negative symptoms and cognitive functioning tend to show less improvement.)
24
Q
During a psychiatric emergency, IM ziprasidone (Geodon) is administered to an assaultive patient. During the next 2 hours, it is of primary importance that the nurse assess for:
a. Tardive dyskinesia
b. Anticholinergic effects
c. Orthostatic hypotension
d. Pseudoparkinsonism
A
C
(The side effect most likely to appear is orthostatic hypotension related to alpha1 receptor blockade preventing peripheral blood vessels from automatically responding to positional change. Anticholinergic effects are of lesser concern. The remaining options are less likely to occur at this point in therapy.)
25
A patient who began haloperidol (Haldol) therapy 24 hours ago tells the nurse that he feels jittery and unable to sit or stand still. The nurse can hypothesize that this report is related to:
a. Dystonia
b. Akathisia
c. Serotonin syndrome
d. Neuroleptic malignant syndrome
B
(Akathisia, an extrapyramidal side effect, is characterized by restlessness, inability to sit still, and the need to pace. It usually occurs early in the course of treatment with a typical antipsychotic drug. The symptomology is not related or seen in the other options.)
26
A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis?
1. This type of crisis is precipitated by unexpected external stressors.
2. This type of crisis is precipitated by preexisting psychopathology.
3. This type of crisis is precipitated by an acute response to an external situational stressor.
4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
ANS: 4
Rationale: The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance.
27
A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing?
1. Maturational/developmental crisis
2. Psychiatric emergency crisis
3. Anticipated life transition crisis
4. Traumatic stress crisis
ANS: 2
Rationale: The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or an inability to assume personal responsibility.
28
A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What long-term outcome is realistic in addressing this client's crisis?
1. The client will change his type A personality traits to more adaptive ones by one week.
2. The client will list five positive self-attributes.
3. The client will examine how childhood events led to his overachieving orientation.
4. The client will return to previous adaptive levels of functioning by week six.
ANS: 4
Rationale: The nurse should identify that a realistic long-term outcome for this client is to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect immediacy of the situation.
29
A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client?
1. Ineffective coping R/T situational crisis AEB powerlessness
2. Anxiety R/T fear of failure
3. Risk for self-directed violence R/T hopelessness
4. Risk for low self-esteem R/T loss events AEB suicidal ideations
ANS: 3
Rationale: The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.
30
After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?
1. "Are you currently thinking about harming yourself?"
2. "Why do you want to harm yourself?"
3. "Have you thought about the consequences of your actions?"
4. "Who is your emergency contact person?"
ANS: 1
Rationale: The nurse should first assess the client for current harmful or suicidal thoughts to minimize risk of harm to the client and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency in which the crisis team should assess for client safety as a priority.
31
An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?
1. Initiate forced medication protocol.
2. Help the client to explore the source of anger.
3. Ignore the act to avoid reinforcing the behavior.
4. With staff support and a show of solidarity, set firm limits on the behavior.
ANS: 4
Rationale: The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor should not warrant forced medication. This intervention may be too restrictive, considering the behavior. Exploring the source of anger may be more appropriate once the client has resolved the current emotion or in a therapeutic group setting. Ignoring the act may further upset the client and is not a method of teaching appropriate behavior.
32
A college student who was nearly raped while jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?
1. “You’ve really been helpful. Can I count on your for continued support?”
2. “I work out in the college gym rather than jogging outdoors.”
3. “I’m really glad I didn’t go home. It would have been hard to come back.”
4. “I carry mace when I jog. It makes me feel safe and secure.”
ANS: 4
Rationale: The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. The final phase of crisis intervention involves evaluating the outcome of the crisis intervention and anticipatory planning.
33
A despondent client who has recently lost her husband of 30 years tearfully states, “I’ll feel a lot better if I sell my house and move away.” Which nursing response is most appropriate?
1. “I’m confident you know what’s best for you.”
2. “This may not be the best time for you to make such an important decision.”
3. “Your children will be terribly disappointed.”
4. “Tell me why you want to make this change.”
ANS: 2
Rationale: During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic.
34
An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression?
1. The client requests prn medications.
2. The client has a tense facial expression and body language.
3. The client refuses to eat lunch.
4. The client sits in group with back to peers.
ANS: 2
Rationale: The nurse should assess that tense facial expressions and body language may indicate that a client’s anger is escalating. The nurse should conduct a thorough assessment of the client’s history of violence and develop interventions for de-escalation.
35
What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place on an inpatient unit?
1. Reinforce unit rules with the client population.
2. Create protocols for the future release of tensions associated with anger.
3. Process client feelings and alleviate fears of undeserved seclusion and restraint.
4. Discuss the situation that led to inappropriate expressions of anger.
ANS: 4
Rationale: The nurse should determine that the purpose for holding a debriefing session with clients and staff after a take-down intervention is to discuss the situation that led to inappropriate behavior. It is important to determine the factors leading to the inappropriate behavior in order to develop future intervention strategies. It is also important to help clients and staff process feelings about the situation.
36
An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation?
1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 1 hour of the initiation of the restraints.
2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 2 hours of the initiation of the restraints.
3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 3 hours of the initiation of the restraints.
4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 4 hours of the initiation of the restraints.
ANS: 1
Rationale: The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) requires that an in-person evaluation by physician or other licensed independent practitioner be conducted within 1 hour of the initiation of restraint or seclusion.
37
A combative adolescent client has been placed in seclusion after all other interventions have failed. Which protocol would apply in this situation?
1. The physician or other licensed independent practitioner must reissue a new order for restraints every 24 hours.
2. The physician or other licensed independent practitioner must reissue a new order for restraints every 8 hours.
3. The physician or other licensed independent practitioner must reissue a new order for restraints every 3 to 4 hours.
4. The physician or other licensed independent practitioner must reissue a new order for restraints every 1 to 2 hours.
ANS: 4
Rationale: The physician or other licensed independent practitioner must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. Restraints should be used as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm to self or others.
38
A nursing instructor is teaching about the Roberts’ Seven-Stage Crisis Intervention Model. Which nursing action should be identified with Stage IV?
1. Collaboratively implement an action plan.
2. Help the client identify the major problems or crisis precipitants.
3. Help the client deal with feelings and emotions.
4. Collaboratively generate and explore alternatives.
ANS: 3
Rationale: The following are the stages of the Roberts’ Seven-Stage Crisis Intervention Model:
Stage I: Psychosocial and Lethality Assessment, Stage II: Rapidly Establish Rapport, Stage III: Identify the Major Problems or Crisis Precipitants, Stage IV: Deal with Feelings and Emotions, Stage V: Generate and Explore Alternatives, Stage VI: Implement an Action Plan, Stage VII: Follow-up.`
39
Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.)
1. “Tell me what happened.”
2. “What coping methods have you used, and did they work?”
3. “Describe to me what your life was like before this happened.”
4. “Let’s focus on the current problem.”
5. “I’ll assist you in selecting functional coping strategies.”
ANS: 1, 2, 3
Rationale: In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies would not occur until after a complete assessment.
40
Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)
A Maintain a calm demeanor.
B Clearly delineate the consequences of the behavior.
C. Use therapeutic touch to convey empathy.
D. Set limits on the behavior.
E. Teach the client to avoid “I” statements related to expression of feelings
ANS: 1, 2, 4
Rationale: The nurse should determine that, when working with an inpatient client with difficulty expressing anger appropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could increase the client’s anger. Teaching would not be appropriate when a client is agitated.
41
Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.)
1. Confusion
2. Paranoia
3. Boisterousness
4. Panic
5. Irritability
ANS: 1, 3, 5
Rationale: The Broset Violence Checklist is a quick, simple, and reliable tool that can be used to assess the risk of potential violence. The behavior assessment categories include: confusion, irritability, boisterousness, physical threats, and verbal threats.
42
Order the following stages of Roberts' Seven-Stage Crisis Intervention Model.
1. ________ Deal with feelings and emotions.
2. ________ Generate and explore alternatives.
3. ________ Rapidly establish rapport.
4. ________ Psychosocial and lethality assessment.
5. ________ Identify the major problems or crisis precipitants.
6. ________ Follow up.
7. ________ Implement an action plan.
ANS: The correct order is 4, 5, 2, 1, 3, 7, 6
Rationale: The stages of Roberts' Seven-Stage Crisis Intervention Model include: 1. Psychosocial and lethality assessment; 2. Rapidly establish rapport; 3. Identify the major problems or crisis precipitants; 4. Deal with feelings and emotions; 5. Generate and explore alternatives; 6. Implement an action plan; 7. Follow up.
43
sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem, can be defined as a ______________________.
ANS: crisis
Rationale: A crisis is a sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem. Crises result in a disequilibrium, from which many individuals require assistance to recover.
44
A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that learning has occurred?
1. "These clients recognize their fear as excessive and frequently seek treatment."
2. "These clients have a panic level of fear that is overwhelming and unreasonable."
3. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)."
4. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."
ANS: 2
Rationale: The nursing instructor should evaluate that learning has occurred when the student knows that clients with phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response. Even though the disorder is relatively common among the general population, people seldom seek treatment unless the phobia interferes with ability to function.
45
Which nursing statement to a client about social anxiety disorder versus schizoid personality disorder (SPD) is most accurate?
1. "Clients diagnosed with social anxiety disorder can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications."
2. "Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social anxiety disorder are not."
3. "Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life."
4. "Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social anxiety disorder tend to avoid interactions in all areas of life."
ANS: 3
Rationale: Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.
46
What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?
1. GAD is acute in nature, and panic disorder is chronic.
2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
3. Hyperventilation is a common symptom in GAD and rare in panic disorder.
4. Depersonalization is commonly seen in panic disorder and absent in GAD.
ANS: 4
Rationale: The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.
47
Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?
1. Long-term treatment with diazepam (Valium)
2. Acute symptom control with citalopram (Celexa)
3. Long-term treatment with buspirone (BuSpar)
4. Acute symptom control with ziprasidone (Geodon)
ANS: 3
Rationale: The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.
48
Which symptoms should a nurse recognize that differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?
1. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.
2. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.
3. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.
4. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.
ANS: 1
Rationale: A client diagnosed with OCD experiences both obsessions and compulsions. Clients with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, but do not experience obsessions and compulsions
49
A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse's first priority?
1. Generalized anxiety disorder and a nursing diagnosis of fear
2. Altered sensory perception and a nursing diagnosis of panic disorder
3. Pain disorder and a nursing diagnosis of altered role performance
4. Panic disorder and a nursing diagnosis of anxiety
ANS: 4
Rationale: The nurse should suspect that the client has exhibited signs and symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror
50
A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing response?
1. "I know it's frightening, but try to remind yourself that this will only last a short time."
2. "Death from a panic attack happens so infrequently that there is no need to worry."
3. "Most people who experience panic attacks have feelings of impending doom."
4. "Tell me why you think you are going to die every time you have a panic attack."
ANS: 1
Rationale: The most appropriate nursing response to the client's concerns is to empathize with the client and provide encouragement that panic attacks only last a short period. Panic attacks usually last minutes but can, rarely, last hours. When the nurse states that "Most people who experience panic attacks..." the nurse depersonalizes and belittles the client's feeling
51
A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?
1. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."
2. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder."
3. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks."
4. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."
ANS: 1
Rationale: The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine in which the major risk is physical dependence and tolerance, which may encourage abuse. It can be used on an as-needed basis to reduce anxiety and the related symptoms.
52
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?
1. "My mother also worries unnecessarily. I think it is part of the aging process."
2. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning."
3. "From what you have told me, you should get her to a psychiatrist as soon as possible."
4. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."
ANS: 2
Rationale: The most appropriate response by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.
53
A client is experiencing a severe panic attack. Which nursing intervention would meet this client's physiological need?
1. Teach deep breathing relaxation exercises.
2. Place the client in a Trendelenburg position.
3. Have the client breathe into a paper bag.
4. Administer the ordered prn buspirone (BuSpar).
ANS: 3
Rationale: The nurse can meet this client's physiological need by having the client breathe into a paper bag. Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the client to breathe into a small paper bag held over the mouth and nose. Six to twelve natural breaths should be taken, alternating with short periods of diaphragmatic breathing.
54
A college student is unable to take a final exam owing to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?
A. Non-adherence R/T test taking
B. Ineffective role performance R/T helplessness
C. Altered coping R/T anxiety
D. Powerlessness R/T fear
ANS: C
Rationale: The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that will improve the client's healthy coping skills and reduce anxiety.
55
A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this treatment should the nurse provide?
1. "Using your imagination, we will attempt to achieve a state of relaxation."
2. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response."
3. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety."
4. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."
ANS: 3
Rationale: The nurse should explain to the client that when participating in systematic desensitization he or she will go through a series of increasingly anxiety-provoking steps that will gradually increase tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.
56
A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?
1. The client will refrain from ritualistic behaviors during daylight hours.
2. The client will wake early enough to complete rituals prior to breakfast.
3. The client will participate in three unit activities by day three.
4. The client will substitute a productive activity for rituals by day one.
ANS: 2
Rationale: An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and begin to gradually limit the time allowed for rituals
57
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
1. "I will need scheduled blood work in order to monitor for toxic levels of this drug."
2. "I won't stop taking this medication abruptly because there could be serious complications."
3. "I will not drink alcohol while taking this medication."
4. "I won't take extra doses of this drug because I can become addicted."
ANS: 1
Rationale: The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. This intervention is used when taking lithium (Eskalith) for the treatment of bipolar disorder. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.
58
A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?
1. Sublimation
2. Dissociation
3. Rationalization
4. Intellectualization
ANS: 4
Rationale: The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual process of logic, reasoning, and analysis.
59
A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem?
1. Distract the client with other activities whenever ritual behaviors begin.
2. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
3. Lock the room to discourage ritualistic behavior.
4. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
ANS: 4
Rationale: The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to control interrupting anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions, because they do not help the client gain insight.
60
A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate?
1. High doses of tricyclic medications will be required for effective treatment of OCD.
2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.
3. The dose of Luvox is low because of the side effect of daytime drowsiness.
4. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned.
ANS: 2
Rationale: The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness
61
```
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
A. History of alcohol use disorder
B. History of personality disorder
C. History of schizophrenia
D. History of hypertension
```
ANS: A
Rationale: The nurse should question a prescription of alprazolam for acute anxiety if the client has a history of alcohol use disorder. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance use disorder may be more likely to abuse other addictive substances.
62
```
During her aunt's wake, a four-year-old child runs up to the casket before a mother can stop her. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child?
A. Complicated grieving
B. Altered family processes
C. Ineffective coping
D. Body image disturbance
```
ANS: C
Rationale: Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of hair-pulling disorder, or trichotillomania, may be assigned
63
A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that learning has occurred?
1. Onset of symptoms most commonly occurs in early adolescence and persists until midlife.
2. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years.
3. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death.
4. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.
ANS: 2
Rationale: The onset of the symptoms of agoraphobia most commonly occurs in the 20s and 30s and persists for many years
64
A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.)
1. Fatigue
2. Anorexia
3. Hyperventilation
4. Insomnia
5. Irritability
ANS: 1, 4, 5
Rationale: The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.
65
A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.)
1. Benzodiazepine therapy
2. Systematic desensitization
3. Imploding (flooding)
4. Assertiveness training
5. Aversion therapy
ANS: 2, 3
Rationale: The nurse should explain to the client that systematic desensitization and imploding are the most common behavioral therapies used for treating phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time
66
A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.)
1. Encourage the client to recognize the signs of escalating anxiety.
2. Encourage the client to avoid any situation that causes stress.
3. Encourage the client to employ newly learned relaxation techniques.
4. Encourage the client to cognitively reframe thoughts about situations that generate anxiety.
5. Encourage the client to avoid caffeinated products.
ANS: 1, 3, 4, 5
Rationale: Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety and because not all situations are easily avoidable
67
An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.)
1. Mirror checking
2. Excessive grooming
3. History of an eating disorder
4. History of delusional thinking
5. Skin picking
ANS: 1, 2, 5
Rationale: The DSM-5 lists preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others as a diagnostic criteria for the diagnosis of BDD. Also listed is that at some point during the course of the disorder, the person has performed repetitive behaviors, such as mirror checking, excessive grooming, skin picking, or reassurance seeking.
68
Traits associated with schizoid, obsessive-compulsive, and _____________________ personality disorders are commonly seen in clients with the diagnosis of body dysmorphic disorder.
ANS: narcissistic
Rationale: Traits associated with schizoid, obsessive-compulsive, and narcissistic personality disorders are not uncommon in clients with the diagnosis of BDD
69
Antianxiety drugs are also called ______________________ and minor tranquilizers.
ANS: anxiolytics
Rationale: Antianxiety drugs are also called anxiolytics and minor tranquilizers. Antianxiety agents are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation.
70
Approximately two million American children have experienced the deployment of a parent to Iraq or Afghanistan. How many of these children either lost a parent or have a parent who was wounded in these conflicts?
1. 48,000
2. 26,000
3. 11,000
4. 8,000
ANS: 1
Rationale: More than 48,000 children have either lost a parent or have a parent who was wounded in Iraq or Afghanistan.
71
Research has shown that an adolescent (13 to18 years) would typically exhibit which behavior as a reaction to parental military deployment?
1. May exhibit regressive behaviors and assume blame for parent's departure.
2. May become sullen, tearful, throw temper tantrums, or develop sleep problems.
3. May participate in high-risk behaviors, sexual acting out, and drug or alcohol abuse.
4. May respond to schedule disruptions with irritability and/or apathy and weight loss.
ANS: 3
Rationale: Infants (birth to 12 months) may respond to schedule disruptions with irritability and/or apathy and weight loss. Toddlers (1 to 3 years) may become sullen, tearful, throw temper tantrums, or develop sleep problems. Preschoolers (3 to 6 years) may regress in areas such as toilet training, sleep, separation fears, physical complaints, or thumb sucking and may assume blame for parent's departure. School age children (6 to 12 years) are more aware of potential dangers to parent. May exhibit irritable behavior, aggression, or whininess. May become more regressed and fearful about parent's safety.
Adolescents (13 to 18 years) may be rebellious, irritable, or more challenging of authority. Parents need to be alert to high-risk behaviors, such as problems with the law, sexual acting out, and drug or alcohol abuse.
72
What is the expected feeling and/or behavior experienced by military families during the "sustainment" cycle of deployment, as described by Pincus and associates?
1. Feelings alternate between denial and anticipation of loss.
2. Feelings alternate between excitement and apprehension associated with homecoming.
3. Feelings focus on the establishment of new support systems and new family routines.
4. Feelings focus on the struggle to take charge of the details of the new family structure.
ANS: 3
Rationale: In the pre-deployment cycle, feelings alternate between denial and anticipation of loss. In the redeployment cycle, feelings alternate between excitement and apprehension associated with homecoming. In the sustainment cycle, families establish new support systems and new family routines. In the deployment cycle, the spouse struggles to take charge of the details of living without his or her partner.
73
A nursing instructor is teaching about suicide among active duty military. Which fact should the instructor include in the lesson plan?
1. On average, two suicides a day occur in the U.S. military.
2. From 2005 to 2009, relationship distress factored in more than 25% of Army suicides.
3. Statistically, in 2012, suicide rates of service members surpassed the number killed in combat.
4. Military suicides are associated with a narcissistic personality disorder diagnosis.
ANS: 3
Rationale: On average, one not two suicides a day occur in the U.S. military. From 2005 to 2009, relationship distress factored in more than 50% not 25% of Army suicides. Military suicides are associated with the diagnoses of substance use disorder, major depressive disorder, PTSD, and TBI, not narcissistic personality disorder. Statistically, in 2012, suicide rates of service members surpassed the number killed in combat.
74
A nursing instructor is preparing a lesson plan related to the history of the diagnosis of post-traumatic stress disorder (PTSD). Which of the following facts would be appropriate to include? (Select all that apply.)
1. Between 1950 and 1970, little was written about PTSD.
2. During the 1970s and 1980s, there was a major increase in research on PTSD.
3. During the 1970s and 1980s, much research was related to World War II veterans.
4. PTSD did not appear until the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).
5. PTSD did not appear until the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
ANS: 1, 2, 4
Rationale: Very little was written about PTSD during the years between 1950 and 1970. This absence was followed in the 1970s and 1980s with an explosion in the amount of research and writing on the subject. During this time, much research was related to Vietnam not World War II veterans. PTSD did not appear until the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).
75
Which of the following should a nurse identify as stressors in the lives of military spouses and children? (Select all that apply.)
1. Frequent moves
2. School credit transfer issues
3. Complications of spousal employment
4. Spousal loneliness
5. Loss of military privileges during spousal deployment
ANS: 1, 2, 3, 4
Rationale: The lives of military spouses and children are clearly affected when the service-member's active duty assignments require frequent family moves. These include, among others, school credit transfer issues, complications of spousal employment, and spousal loneliness. Military privileges are not lost during spousal deployment.
76
Owing to the unique challenges experienced by children of active duty military, which of the following fears would a nurse most likely identify? (Select all that apply.)
1. Fear of not being accepted in new schools
2. Fear of being behind academically
3. Fear of not making friends in new schools
4. Fear of losing athletic standing
5. Fear of discrimination from new school faculty
ANS: 1, 2, 3, 4
Rationale: Military children face unique challenges. They fear not being accepted, being behind academically, not making friends, and losing athletic standing as they move from one school to another. Fear of discrimination from new school faculty has not been shown as a realistic fear in this population.
77
After reporting a sexual assault, a female soldier is diagnosed with a personality disorder. Which of the following consequences may result? (Select all that apply.)
1. Court-martial proceedings
2. Loss of health-care benefits
3. Loss of service-related disability compensation
4. Stigma of a psychiatric diagnosis
5. Service discharge
ANS: 2, 3, 4, 5
Rationale: Some military women who report their sexual assaults are discharged with a psychiatric diagnosis of personality disorder or adjustment disorder. Some of the consequences of this diagnosis are loss of health-care benefits, loss of service-related disability compensation, and the stigma of a psychiatric diagnosis. The report of a sexual assault would not lead to courtmartial proceedings for the victim.
78
Members of various components of the National Guard and U.S. Military Reserves are
classified as the _________________________/_______________________
ANS: Ready Reserve
79
10. An association between Parkinson’s disease and combat-related traumatic brain injury (TBI)
has been established. This disorder may develop years after TBI as a result of damage to the
_________________________/_______________________.
ANS: basal ganglia
80
1. Which changes in brain biochemical function is most associated with suicidal behavior?
a. Dopamine excess
b. Serotonin deficiency
c. Acetylcholine excess
d. Gamma-aminobutyric acid deficiency
ANS: B
Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises.
81
A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?
a. Calling parents
b. Excessive crying
c. Giving away sweaters
d. Staying alone in a dorm room
ANS: C
Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go.
82
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to:
a. current stress level.
b. mood disturbance.
c. suicide potential.
d. level of anxiety.
ANS: C
The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.
83
A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority?
a. Powerlessness
b. Social isolation
c. Risk for suicide
d. Ineffective management of the therapeutic regimen
ANS: C
This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.
84
A person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will:
a. verbalize a will to live by the end of the second hospital day.
b. describe two new coping mechanisms by the end of the third hospital day.
c. accurately delineate personal strengths by the end of first week of hospitalization.
d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.
ANS: D
Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.
85
A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects:
a. denial.
b. anger.
c. anxiety.
d. rescue feelings.
ANS: A
The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario.
86
An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be:
a. "Why do you want to kill yourself?"
b. "Do you have access to medications?"
c. "Have you been taking drugs and alcohol?"
d. "Did something happen with your parents?"
ANS: B
The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.
87
An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention.
a. Supervise the patient 24 hours a day.
b. Begin discharge planning for the patient.
c. Refer the patient to art and music therapists.
d. Consider the discontinuation of suicide precautions.
ANS: A
The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated.
88
A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract.
a. "I will not try to harm myself during the next 24 hours."
b. "I will not make a suicide attempt while I am hospitalized."
c. "For the next 24 hours, I will not kill or harm myself in any way."
d. "I will not kill myself until I call my primary nurse or a member of the staff."
ANS: C
The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, "I am not going to harm myself, I am going to kill myself," or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.
89
A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to:
a. assess the lethality of a suicide plan.
b. encourage expression of anger.
c. establish a rapport with the patient.
d. determine risk factors for suicide.
ANS: C
Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.
90
Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering suicide."
a. "I'm glad you shared this. Please do not worry. We will handle it together."
b. "I think you should admit yourself to the hospital to get help."
c. "We need to talk about the good things you have to live for."
d. "Bringing this up is a very positive action on your part."
ANS: D
This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem-solving strategies.
91
Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide?
a. Participating in reminiscence therapy
b. Attending a self-help group for survivors
c. Contracting for two sessions of group therapy
d. Completing a psychological postmortem assessment
ANS: B
Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide
92
Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?
a. As depression lifts, physical energy becomes available to carry out suicide.
b. Suicide may be precipitated by a variety of internal and external events.
c. Suicidal patients have difficulty using social supports.
d. Suicide is an impulsive act.
ANS: A
Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.
93
A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?
a. "I wish I were dead."
b. "Life is not worth living."
c. "I have a plan that will fix everything."
d. "My family will be better off without me."
ANS: C
Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.
94
A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?
a. "Are you having thoughts of suicide?"
b. "I am not sure I understand what you are trying to say."
c. "Try to stay hopeful. Things have a way of working out."
d. "Tell me more about what interested you before you began feeling depressed."
ANS: A
The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.
95
A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?
a. "Let's make a list of all your problems and think of solutions for each one."
b. "I'm happy you're taking control of your problems and trying to find solutions."
c. "When you have bad feelings, try to focus on positive experiences from your life."
d. "Let's consider which problems are most important and which are less important."
ANS: D
The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.
96
When assessing a patient's plan for suicide, what aspect has priority?
a. Patient's financial and educational status
b. Patient's insight into suicidal motivation
c. Availability of means and lethality of method
d. Quality and availability of patient's social support
ANS: C
If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.
97
Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered:
a. mentally ill.
b. intent on dying.
c. cognitively impaired.
d. experiencing hopelessness.
ANS: D
Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.
98
Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention?
a. "I am mixed up, but I know I need help."
b. "I have no one for help or support."
c. "It is worse when you are a person of color."
d. "I tried to get attention before I shot myself."
ANS: B
Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.
99
The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is:
a. hopelessness.
b. sadness.
c. elation.
d. anger.
ANS: A
Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.
100
Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?
a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night
b. Turning on the oven and letting gas escape into the apartment during the night
c. Cutting the wrists in the bathroom while the spouse reads in the next room
d. Overdosing on aspirin with codeine while the spouse is out with friends
ANS: A
This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.
101
Which individual in the emergency department should be considered at the highest risk for completing suicide?
a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma
b. A 38-year-old single African-American female church member with fibrocystic breast disease
c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes
d. A 79-year-old single white man with cancer of the prostate gland
ANS: D
High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.
102
A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?
a. No risk
b. Low level
c. Moderate level
d. High level
ANS: D
The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.
103
A staff nurse tells another nurse, "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse.
a. "That action would seem appropriate."
b. "A score over 8 requires immediate hospitalization."
c. "I think you should strongly consider hospitalization for this patient."
d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."
ANS: B
A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.
104
25. A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event?
a. Request the public information officer to make an announcement to the local media.
b. Hold a staff meeting to express feelings and plan the care for other patients.
c. Ask the patient's roommate not to discuss the event with other patients.
d. Quickly discharge as many patients as possible to prevent panic.
ANS: B
Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care.
105
A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?
1. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure.
2. Establish room restrictions, because the client’s threat is an attempt to manipulate the staff.
3. Place client on one-to-one suicide precautions, because specific plans likely lead to attempts.
4. Call an emergency treatment team meeting, because the client’s threat must be addressed
ANS: 3
Rationale: The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.
106
In planning care for a suicidal client, which correctly written outcome should be a nurse’s first priority?
1. The client will not physically harm self.
2. The client will express hope for the future by day three.
3. The client will establish a trusting relationship with the nurse.
4. The client will remain safe during hospital stay.
ANS: 4
Rationale: The nurse’s first priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse’s first priority. Outcomes should be client-centered, specific, realistic, measureable, and must also include a time frame.
107
A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?
1. To prevent increased intracranial pressure resulting from anoxia.
2. To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation.
3. To prevent anoxia resulting from medication-induced paralysis of respiratory muscles.
4. To prevent blocked airway, resulting from seizure activity.
ANS: 3
Rationale: The nurse administers 100% oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles.
108
Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client?
1. On his or her side, to prevent aspiration
2. In high Fowler’s position, to prevent increased intracranial pressure
3. In Trendelenburg’s position, to promote blood flow to vital organs
4. In prone position, to prevent airway blockage
ANS: 1
Rationale: The nurse should place a client who has received ECT on his or her side, to prevent aspiration.
109
A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?
1. Altered communication R/T feelings of worthlessness AEB anhedonia
2. Social isolation R/T poor self-esteem AEB secluding self in room
3. Altered thought processes R/T hopelessness AEB persecutory delusions
4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
ANS: 2
Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and grooming.
110
A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse’s priority intervention at this time?
1. Obtaining an order for locked seclusion until client is no longer suicidal.
2. Conducting 15-minute checks to ensure safety.
3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
4. Encouraging client to express feelings related to suicide.
ANS: 3
Rationale: The nurse’s priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.
111
A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis?
1. The client is disheveled and malodorous.
2. The client refuses to interact with others and isolates self in room.
3. The client is unable to feel any pleasure.
4. The client has maxed-out charge cards and exhibits promiscuous behaviors.
ANS: 4
Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode.
112
A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse’s priority at this time?
1. Give the client off-unit privileges as positive reinforcement.
2. Encourage the client to share mood improvement in group.
3. Increase the level of this client’s suicide precautions.
4. Request that the psychiatrist reevaluate the current medication protocol.
ANS: 3
Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.
113
A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis?
1. Thyroid-stimulating hormone (TSH) level of 25 U/mL
2. Potassium (K+) level of 4.2 mEq/L
3. Sodium (Na+) level of 140 mEq/L
4. Calcium (Ca2+) level of 9.5 mg/dL
ANS: 1
Rationale: A diagnosis of major depressive episode may be ruled out if the client’s lab results reveal a TSH level of 25 U/mL. Normal levels of TSH range from 2 to 10 U/mL. High levels of TSH indicate low thyroid function. The client’s high TSH value may indicate hypothyroidism, which can lead to depressive symptoms. The DSM-5 criteria for the diagnosis of major depressive episode states that this diagnosis must not be attributable to the direct physiological effects of another medical condition.
114
A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?
1. According to psychoanalytic theory, depression is a result of negative perceptions.
2. According to object-loss theory, depression is a result of overprotection.
3. According to learning theory, depression is a result of repeated failures.
4. According to cognitive theory, depression is a result of anger turned inward.
ANS: 3
Rationale: The nurse should assess that, according to learning theory, this client’s depressive symptoms may have resulted from repeated failures. The learning theory is a model of “learned helplessness” in which multiple life failures cause the client to abandon future attempts to succeed.
115
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?
1. The attention during the assessment is beneficial in decreasing social isolation.
2. Depression can generate somatic symptoms that can mask actual physical disorders.
3. Physical health complications are likely to arise from antidepressant therapy.
4. Depressed clients avoid addressing physical health and ignore medical problems.
ANS: 2
Rationale: The nurse should determine that a client with a diagnosis of major depressive episode needs a full physical health assessment, because depression can generate somatic symptoms that can mask actual physical disorders.
116
A nurse is planning care for a 13 -year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents?
1. Paroxetine (Paxil)
2. Sertraline (Zoloft)
3. Citalopram (Celexa)
4. Escitalopram (Lexipro)
ANS: 4
Rationale: Fluoxetine (Prozac) has been approved by the FDA to treat depression in children and adolescents, and escitalopram was approved in 2009 for treatment of depression in adolescents aged 12 to 17 years. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents
117
A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam?
1. To rule out bipolar disorder
2. To rule out schizophrenia
3. To rule out neurocognitive disorder
4. To rule out personality disorder
ANS: 3
Rationale: A mini-mental status exam should be performed to rule out neurocognitive disorder. The client may be experiencing reversible dementia, which can occur as a result of depression.
118
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client’s safety upon discharge?
1. Provide a 6-month supply of Elavil to ensure long-term compliance.
2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments.
3. Provide pill dispenser as a memory aid.
4. Provide education regarding the avoidance of foods containing tyramine.
ANS: 2
Rationale: The health-care provider should provide no more than a 1-week supply of amitriptyline, with refills contingent on follow-up appointments, as an appropriate intervention to maintain the client’s safety. Antidepressants, which are central nervous system depressants, can be used to commit suicide. Also these medications can precipitate suicidal thoughts during the initial use period. Limiting the amount of medication and monitoring the client weekly would be appropriate interventions to address the client’s risk for suicide.
119
An older client has recently been prescribed sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?
1. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs)
2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI)
3. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI
4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs
ANS: 4
Rationale: The nurse should suspect that the client is suffering from serotonin syndrome; possibly caused by ingesting two different SSRI’s (sertraline and paroxetine). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.
120
A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing response?
1. “This combination of drugs can lead to delirium tremens.”
2. “A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.”
3. “That’s a good idea. There have been good results with the combination of these two drugs.”
4. “The only disadvantage would be the exorbitant cost of the MAOI.”
ANS: 2
Rationale: The nurse should explain to the client that combining an MAOI and fluvoxamine, an SSRI, can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches, with occasional photophobia, sensations of choking, palpitations, and a feeling of “dread.”
121
A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client?
1. Zung Depression Scale
2. Hamilton Depression Rating Scale
3. Beck Depression Inventory
4. AIMS Depression Rating Scale
2. Hamilton Depression Rating Scale
122
The severity of depressive symptoms in the postpartum period varies from a feeling of the “blues,” to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms?
1. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions)
2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)
3. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia)
4. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)
2. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about
inability to care for baby)
123
A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of “automatic thoughts.” Which client statement is evidence of the “automatic thought” of discounting positives?
1. “It’s all my fault for trusting him.”
2. “I don’t play games. I never win.”
3. “She never visits because she thinks I don’t care.”
4. “I don’t have a green thumb. Any old fool can grow a rose.”
4. I don’t have a green thumb. Any old fool can grow a rose.
124
A client, who is taking transdermal selegiline (Emsam) for depressive symptoms, states, “My physician told me there was no need to worry about dietary restrictions.” Which would be the most appropriate nursing response?
1. “Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended.”
2. “You must have misunderstood. An MAOI like Emsam always has dietary restrictions.”
3. “Only oral MAOIs require dietary restrictions.”
4. “All transdermal MAOIs do not require dietary modifications.”
1. Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended
125
After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn’t seem as effective as before. Which question should the nurse ask to determine the cause of this problem?
1. “Are you consuming foods high in tyramine?”
2. “How many packs of cigarettes do you smoke daily?”
3. “Do you drink any alcohol?”
4. “Are you taking St. John’s wort?”
2. How many packs of cigarettes do you smoke daily?
126
A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.)
1. Sad mood on most days
2. Mood rating of 2 out of 10 for the past 6 months
3. Labile mood
4. Sad mood for the past 3 years after spouse’s death
5. Pressured speech when communicating
1. Sad mood on most days
| 4. Sad mood for the past 3 years after spouses death
127
An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.)
A Gender differences in social opportunities that occur with age
B Drastic temperature and barometric pressure changes
C A seasonal increase in social interactions
D Variations in serotonergic functioning
E Inaccessibility of resources for dealing with life stressors
2. Drastic temperature and barometric pressure changes
3. A seasonal increase in social interactions
4. Variations in serotonergic functioning
128
A client is prescribed phenelzine (Nardil). Which of the following statements by the client should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.)
1. “I’ll have to let my surgeon know about this medication before I have my cholecystectomy.”
2. “I guess I will have to give up my glass of red wine with dinner.”
3. “I’ll have to be very careful about reading food and medication labels.”
4. “I’m going to miss my caffeinated coffee in the morning.”
5. “I’ll be sure not to stop this medication abruptly.”
1. Ill have to let my surgeon know about this medication before I have my cholecystectomy.
2. I guess I will have to give up my glass of red wine with dinner.
3. Ill have to be very careful about reading food and medication labels.
5. Ill be sure not to stop this medication abruptly
129
A nursing instructor is teaching about the new DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD). Which of the following information should the instructor include? (Select all that apply.)
1. Symptoms include verbal rages or physical aggression toward people or property.
2. Temper outbursts must be present in at least two settings (at home, at school, or with peers).
3. DMDD is characterized by severe recurrent temper outbursts.
4. The temper outbursts are manifested only behaviorally.
5. Symptoms of DMDD must be present for 18 or more months to meet diagnostic criteria.
1. Symptoms include verbal rages or physical aggression toward people or property.
2. Temper outbursts must be present in at least two settings (at home, at school, or with peers).
3. DMDD is characterized by severe recurrent temper outbursts.
130
Order the depressive disorders and their predominant affective symptoms according to level
of severity.
________ Dysthymic disorder (pessimistic outlook, low self-esteem)
________ Grief (feelings of anger, anxiety, guilt, helplessness)
________ Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia)
________ Transient depression (sadness, dejection, feeling downhearted, having the blues)
ANS: The correct order is 3, 2, 4,1
131
___________________________ is a pervasive and sustained emotion that may have a
major influence on a person’s perception of the world.
ANS: Mood
132
A highly agitated client paces the unit and states, “ I could buy and sell this place.” The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior?
A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric."
B. "Mood euthymic. Exhibiting magical thinking. Restless."
C. "Mood labile. Exhibiting delusions of reference. Hyperactive."
D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."
ANS: D
The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.
133
A client diagnosed with bipolar disorder i distraught over insomnia experienced ove the last 3 nights and a 12 pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?
A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
C. Risk for suicide R/T powerlessness AEB insomnia and anorexia
D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
ANS: B
The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.
134
```
A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes?
Client Outcomes:
1. Maintains nutritional status.
2. Interacts appropriately with peers.
3. Remains free from injury.
4. Sleeps 6 to 8 hours a night.
A. 2, 1, 3, 4
B. 4, 1, 2, 3
C. 3, 1, 4, 2
D. 1, 4, 2, 3
```
ANS: C
The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's physical and safety needs.
135
A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?
A. Risk for suicide R/T hopelessness
B. Anxiety: severe R/T hyperactivity
C. Imbalanced nutrition: less than body requirements R/T refusal to eat
D. Dysfunctional grieving R/T loss of employment
ANS: A
The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.
136
A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate
(Lithobid) because of excessive weight gain. In order to increase adherence, which medication
should a nurse anticipate that a physician may prescribe?
```
A Sertraline (Zoloft)
B Valproic acid (Depakote)
C Trazodone (Desyrel)
D Paroxetine (Paxil
```
B. Valproic acid (Depakote)
137
A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician
prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions
the Zyprexa order. Which is the appropriate nursing response?
A “Zyprexa in combination with Eskalith cures manic symptoms.”
B “Zyprexa prevents extrapyramidal side effects.”
C “Zyprexa ensures a good night’s sleep.”
D “Zyprexa calms hyperactivity until the Eskalith takes effe
D
The nurse should explain to the client’s spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately reduce hyperactive symptoms in acute manic episodes
138
A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder
approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time
frame. Which is the appropriate nursing response?
A “That’s strange. Weight loss is the typical pattern.”
B “What have you been eating? Weight gain is not usually associated with lithium.”
C “Weight gain is a common, but troubling, side effect.”
D “Weight gain only occurs during the first month of treatment with this dru
C The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.
139
A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one
year. The client presents in an emergency department with a temperature of 101F (38C), severe
diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
4. Symptoms indicate lithium carbonate toxicity
140
What tool should a nurse use to differentiate occasional spontaneous behaviors of children
from behaviors associated with bipolar disorder?
2. FIND tool
141
A nursing instructor is discussing various challenges in the treatment of clients diagnosed
with bipolar disorder. Which student statement demonstrates an understanding of the most
critical challenge in the care of these clients?
A.
“Treatment is compromised when clients can’t sleep.”
B.
“Treatment is compromised when irritability interferes with social interactions.”
C.
“Treatment is compromised when clients have no insight into their problems.”
D.
“Treatment is compromised when clients choose not to take their medications.”
4. Treatment is compromised when clients choose not to take their medications
142
A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention
would be implemented to achieve the outcome of Client will gain 2 lb by the end of the week?
A.
Provide client with high-calorie finger foods throughout the day.
B.
Accompany client to cafeteria to encourage adequate dietary consumption.
C.
Initiate total parenteral nutrition to meet dietary needs.
D.
Teach the importance of a varied diet to meet nutritional needs.
1. Provide client with high-calorie finger foods throughout the day.
143
A nursing instructor is teaching about bipolar disorders. Which statement differentiates the
DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?
1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania.
2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania.
3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.
4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.
3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.
144
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?
1. Increase the dosage of fluoxetine.
2. Discontinue the fluoxetine and rethink the client’s diagnosis.
3. Order benztropine (Cogentin) to address extrapyramidal symptoms.
4. Order olanzapine (Zyprexa) to address altered thoughts.
2. Discontinue the fluoxetine and rethink the client’s diagnosis.
145
Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar
disorder?
1. Medication adherence
2. Empowerment of the consumer
3. Total absence of symptoms
4. Improved psychosocial relationships
2. Empowerment of the consumer
146
Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? (Select all
that apply.)
1. Avoid excessive use of beverages containing caffeine.
2. Maintain a consistent sodium intake.
3. Consume at least 2,500 to 3,000 mL of fluid per day.
4. Restrict sodium content.
5. Restrict fluids to 1,500 mL per day.
1. Avoid excessive use of beverages containing caffeine.
2. Maintain a consistent sodium intake.
3. Consume at least 2,500 to 3,000 mL of fluid per day.
147
A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the
following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that
apply.)
1. Symptoms lasting for a minimum of two years
2. Numerous periods with manic symptoms
3. Possible comorbid diagnosis of a delusional disorder
4. Symptoms cause clinically significant impairment in important areas of functioning
5. Depressive symptoms that do not meet the criteria for major depressive episode
4. Symptoms cause clinically significant impairment in important areas of functioning
5. Depressive symptoms that do not meet the criteria for major depressive episode
148
Which of the following rationales by a nurse explain to parents why is it difficult to diagnose
a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.)
1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.
2. Children are naturally active, energetic, and spontaneous.
3. Neurotransmitter levels vary considerably in accordance with age.
4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.
5. Genetic predisposition is not a reliable diagnostic determinant.
1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.
2. Children are naturally active, energetic, and spontaneous.
149
___________________________ is an alteration in mood that is expressed by feelings of
elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and
speaking.
ANS: Mania
150
Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which statement regarding a client's home environment should a nurse associate with the development of anorexia nervosa?
1. The home environment maintains loose personal boundaries.
2. The home environment places an overemphasis on food.
3. The home environment is overprotective and demands perfection.
4. The home environment condones corporal punishment.
ANS: 3
Rationale: The nurse should assess that a home environment that is overprotective and demands perfection may be a major influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against the parents viewed by the child as a means of gaining and remaining in control.
151
A client's altered body image is evidenced by claims of "feeling fat," even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem?
1. The client will consume adequate calories to sustain normal weight.
2. The client will cease strenuous exercise programs.
3. The client will perceive personal ideal body weight and shape as normal.
4. The client will not express a preoccupation with food.
ANS: 3
Rationale: The nurse should identify that the appropriate outcome for this client is to perceive personal ideal body weight and shape as normal. Additional goals include accepting self based on self-attributes instead of appearance and to realize that perfection is unrealistic.
152
A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration. Which explanation for this complication of bulimia nervosa, should the nurse provide?
1. The emesis produced during purging is acidic and corrodes the tooth enamel.
2. Purging causes the depletion of dietary calcium.
3. Food is rapidly ingested without proper mastication.
4. Poor dental and oral hygiene leads to dental caries
ANS: 1
Rationale: The nurse should explain to the client diagnosed with bulimia nervosa that his or her teeth will eventually deteriorate, because the emesis produced during purging is acidic and corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.
153
A nurse is teaching a client diagnosed with an eating disorder about behavior-modification programs. Why is this intervention the treatment of choice?
1. It helps the client correct a distorted body image.
2. It addresses the underlying client anger.
3. It manages the client's uncontrollable behaviors.
4. It allows clients to maintain control
ANS: 4
Rationale: Behavior-modification programs are the treatment of choice for clients diagnosed with eating disorders, because these programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques function to restore healthy weight.
154
A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects insight related to this disorder?
1. "Skaters need to be thin to improve their daily performance."
2. "All the skaters on the team are following an approved 1200-calorie diet."
3. "The exercise of skating reduces my appetite but improves my energy level."
4. "I am angry at my mother. I can only get her approval when I win competitions."
ANS: 4
Rationale: The client reflects insight when referring to feelings toward family dynamics that may have influenced the development of the disease. Families who are overprotective and perfectionistic can contribute to the development of anorexia nervosa.
155
The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing response?
1. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions."
2. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."
3. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support."
4. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."
ANS: 2
Rationale: The nurse should educate the family on the correlation between certain familial patterns and anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of anorexia nervosa
156
A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?
1. The client gained two pounds in one week.
2. The client focused conversations on nutritious food.
3. The client demonstrated healthy coping mechanisms that decreased anxiety.
4. The client verbalized an understanding of the etiology of the disorder
NS: 3
Rationale: The nurse should identify that a client who demonstrates healthy coping mechanisms to decrease anxiety indicates a positive behavioral change. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behavior
157
A morbidly obese client is prescribed an anorexiant medication. The nurse should expect to teach the client about which medication?
1. Phentermine (Mirapront)
2. Dexfenfluramine (Redux)
3. Sibutramine (Meridia)
4. Pemoline (Cylert
ANS: 1
Rationale: The nurse should teach the client that phentermine is an anorexiant medication prescribed for morbidly obese clients. Phentermine works on the hypothalamus to stimulate the adrenal glands to release norepinephrine, a neurotransmitter that signals a fight-or-flight response, reducing hunger. Dexfenfluramine has been removed from the market because of its association with serious heart and lung disease. Several deaths have been associated with the use of sibutramine by high-risk clients. Based on pressure from the FDA, the manufacturer issued a recall of the drug in October 2010. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression
158
A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders?
1. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not.
2. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not.
3. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not.
4. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not
ANS: 1
Rationale: The nurse should understand that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia do not. Anorexia is characterized by a morbid fear of obesity and often results in low caloric and nutritional intake. Bulimia is characterized by episodic, rapid consumption of large quantities of food followed by purging
159
A client diagnosed with a history of anorexia nervosa comes to an outpatient clinic after being medically cleared. The client states, "My parents watch me like a hawk and never let me out of their sight." Which nursing diagnosis would take priority at this time?
1. Altered nutrition less than body requirements
2. Altered social interaction
3. Impaired verbal communication
4. Altered family processes
ANS: 4
Rationale: The nurse should determine that once the client has been medically cleared, the diagnosis of altered family process should take priority. Clients diagnosed with anorexia nervosa have a need to control and feel in charge of their own treatment choices. Behavioral-modification therapy allows the client to maintain control of eating
160
A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? (Select all that apply.)
1. Binge eating with a diagnosis of obesity
2. Bingeing and purging with a diagnosis of bulimia nervosa
3. Weight loss with a diagnosis of anorexia nervosa
4. Amenorrhea with a diagnosis of anorexia nervosa
5. Emaciation with a diagnosis of bulimia nervosa
ANS: 1, 2
Rationale: The nurse should identify that topiramate is the drug of choice when treating binge eating with a diagnosis of obesity or bingeing and purging with a diagnosis of bulimia nervosa. Topiramate is an anticonvulsant that produces a significant decline in binge frequency and reduction in body weight.
161
A nursing instructor is teaching about the DSM-5 criteria for the diagnosis of binge-eating disorder. Which of the following student statements indicates that further instruction is needed? (Select all that apply.)
1. "In this disorder, binge eating occurs exclusively during the course of bulimia nervosa."
2. "In this disorder, binge eating occurs, on average, at least once a week for three months."
3. "In this disorder, binge eating occurs, on average, at least two days a week for six months."
4. "In this disorder, distress regarding binge eating is present."
5. "In this disorder, distress regarding binge eating is absent."
ANS: 1, 3, 5
Rationale: According to the DSM-5 criteria for the diagnosis of binge-eating disorder, binge eating should not occur exclusively during the course of anorexia nervosa or bulimia nervosa. The new time frame criteria in the DSM-5 states that binge eating must occur, on average, at least once a week for three months not two days a week for six months. The DSM-5 criteria states that distress regarding binge eating would be present
162
Which of the following would contribute to a client's excessive weight gain? (Select all that apply.)
1. A hypothalamus lesion
2. Hyperthyroidism
3. Diabetes mellitus
4. Cushing's disease
5. Low levels of serotonin
ANS: 1, 3, 4
Rationale: Lesions in the appetite and satiety centers in the hypothalamus may contribute to overeating and lead to obesity. Hypothyroidism, not hyperthyroidism, is a problem that interferes with basal metabolism and may lead to weight gain. Weight gain can also occur in response to the decreased insulin production of diabetes mellitus and the increased cortisone production of Cushing's disease. New evidence also exists to indicate that low levels of the neurotransmitter serotonin may play a role in compulsive eating
163
The diagnosis of __________________ ___________________includes the symptoms of gross distortion of body image, preoccupation with food, and refusal to eat
ANS: anorexia nervosa
Rationale: Anorexia nervosa is characterized by a morbid fear of obesity. Symptoms include gross distortion of body image, preoccupation with food, and refusal to eat
164
The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time is termed ________________________.
ANS: bingeing
Rationale: The episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period of time is termed bingeing. Bingeing is a classic symptom of the eating disorder defined as bulimia nervosa
165
To rid the body of excessive calories, a client diagnosed with bulimia nervosa may engage in ______________________ behaviors, which include self-induced vomiting, or the misuse of laxatives, diuretics, or enemas
ANS: purging
Rationale: To rid the body of excessive calories, a client diagnosed with bulimia nervosa may engage in purging behaviors, which include self-induced vomiting or the misuse of laxatives, diuretics, or enemas. In addition to these behaviors, other inappropriate compensatory behaviors, such as fasting or excessive exercise may be noted
