Mental Health - Exam 3

Question 1

S, age 18, has been diagnosed with anorexia nervosa. A short-term goal related to the nursing diagnosis Imbalanced nutrition: less than body requirements would be: client will

a. gain 1 to 3 pounds each week
b. state she feels better about her situation within 2 weeks
c. identify two emotional supports within 3 weeks
d. identify an alternative coping skill prior to discharge

Answer 1

a. gain 1 to 3 pounds each week

Question 2

C’s skin has a yellow cast, her hair is limp and dry, and her body is covered by fine downy hair. Her weight is 70 pounds and her height is 5 feet 4 inches. C remains quiet and sullen during the physical assessment, but does say, “I don’t intend to eat until I lose enough weight to look thin.” An initial nursing diagnosis for C would be

a. Disturbed body image due to weight loss
b. Anxiety related to fear of weight gain
c. Ineffective coping related to lack of conflict resolution skills
d. Imbalanced nutrition: less than body requirements related to self-starvation

Answer 2

d. Imbalanced nutrition: less than body requirements related to self-starvation

Question 3

A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:

a. gain 1 to 2 pounds.
b. exercise 1 hour daily.
c. take a laxative every 3 days.
d. weigh self accurately using balanced scales.

Answer 3

a. gain 1 to 2 pounds.

Question 4

From a cognitive perspective, which characteristic is the nurse most likely to assess in a client with an eating disorder?

a. carefree flexibility
b. open displays of emotion
c. rigidity
d. high spirits and optimism

Answer 4

c. rigidity

Question 5

Clients with eating disorders have made each of the following statements. Which would NOT be considered a cognitive distortion?

a. “Gaining a pound is as much of a disaster as gaining 100.”
b. “Everything I eat goes right to fat on my hips.”
c. “Bingeing is the only way I can soothe myself.”
d. “I’ve been coping with disappointment by overeating.”

Answer 5

d. “I’ve been coping with disappointment by overeating.”

Question 6

J was admitted last night with a compound fracture of the femur, sustained in a fall while intoxicated. J’s blood alcohol level was not assessed on admission. The nurse should

a. request that the blood be drawn stat for this test
b. do nothing since the time for the assessment has passed
c. obtain a Breathalyzer from the emergency department to assess blood alcohol level.
d. ask about quantity and frequency of recent drinking and when J had her last drink.

Answer 6

d. ask about quantity and frequency of recent drinking and when J had her last drink.

Question 7

J was admitted with a compound fracture of the femur, sustained in a fall while intoxicated. Two days later the client believes bugs are crawling on her bed. She is anxious, agitated, and diaphoretic. A nursing diagnosis of high priority that should be developed is

a. Ineffective coping
b. Ineffective health maintenance
c. Risk for injury
d. Ineffective denial

Answer 7

c. Risk for injury

Question 8

T, a retiree, admits himself to an alcoholism rehabilitation program. On admission, he tells the nurse that he’s a social drinker, usually having a drink or two at brunch and a few cocktails during the afternoon, wine at dinner, and several drinks throughout the evening. The client can be assessed as using

a. projection
b. rationalization
c. denial
d. introjection

Answer 8

c. denial

Question 9

The most non-therapeutic approach for the nurse to take when working with an alcoholic client who is entering treatment is

a. empathetic
b. strongly confrontive
c. supportive
d. encouraging

Answer 9

b. strongly confrontive

Question 10

A student who is assigned to observe in the chemical dependency center asks, “What’s the difference between drug abuse and drug dependence?” The nurse replies, “Abuse implies maladaptive consistent use of the drug despite experiencing problems related to the drug.” Which statement should be used to complete the answer?

a. Dependence involves lack of control of drug use, tolerance, and withdrawal symptoms when intake is reduced or stopped.
b. Dependence occurs when psychoactive drug use interferes with the work of neurotransmitters.
c. Dependence refers to symptoms that occur when two or more drugs affecting the CNS are used for their additive effects.
d. Dependence refers to taking a combination of drugs to weaken or inhibit the effect of another drug.

Answer 10

a. Dependence involves lack of control of drug use, tolerance, and withdrawal symptoms when intake is reduced or stopped.

Question 11

An individual who has just “shot up” with heroin will display

a. anxiety, restlessness, paranoid delusions
b. muscle aching, dilated pupils, tachycardia
c. heightened sexuality, insomnia, euphoria
d. drowsiness, constricted pupils, slurred speech

Answer 11

d. drowsiness, constricted pupils, slurred speech

Question 12

Which drug, if used alone, normally produces the least medically compromising (risk for injury) withdrawal syndrome?

a. alcohol
b. heroin
c. amphetamine
d. diazepam

Answer 12

b. heroin

Question 13

B, a newly admitted client with paranoid schizophrenia, is hyper vigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting a way to kill him. The nurse may correctly assess this behavior as

a. an idea of reference
b. a delusion of infidelity
c. an auditory hallucination
d. echolalia

Answer 13

a. an idea of reference

Question 14

A schizophrenic client believes that his thoughts can be heard by others. This is considered:

a. thought broadcasting
b. thought insertion
c. thought withdrawal
d. thought control

Answer 14

a. thought broadcasting

Question 15

B is a client with paranoid schizophrenia who was admitted to the mental health unit after arguing with co-workers and threatening to kill them. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking are plotting to kill him. Based on data gathered at this point, what two nursing diagnoses should the nurse consider?

a. Disturbed thought processes and Risk for other-directed violence
b. Spiritual distress and Social isolation
c. Risk for loneliness and Deficient knowledge
d. Disturbed personal identity and Noncompliance

Answer 15

a. Disturbed thought processes and Risk for other-directed violence

Question 16

A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, “They’re all plotting to destroy me. Isn’t that true?” Which would be the most appropriate response?

a. “No, that is not true. People here are trying to help you if you will let them.”
b. “Let’s think about it: what reason would people have to want to destroy you?”
c. “Thinking that people want to destroy you must be very frightening.”
d. “That doesn’t make sense; staff are health care workers, not murderers.”

Answer 16

c. “Thinking that people want to destroy you must be very frightening.”

Question 17

When a patient diagnosed with paranoid schizophrenia was discharged from the unit 6 months ago, the plan was for him to take chlorpromazine (Thorazine), a conventional (first generation) antipsychotic medication, 300 mg po daily. He tells the nurse he stopped taking his pills after a few months because they made him feel like a “zombie.” What other common side effects should the nurse determine if the patient experienced?

a. Sweating, nausea, and weight gain
b. Sedation, tremor, and muscle stiffness
c. Headache, watery eyes, and runny nose
d. Mild fever, sore throat, and skin rash

Answer 17

b. Sedation, tremor, and muscle stiffness

Question 18

A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient’s skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient’s recent presentation. The patient is likely experiencing ________ , and the nurse should ___________.

a. anticholinergic toxicity…check vital signs and prepare to use a cooling blanket stat
b. relapse of her psychosis…administer PRN antipsychotic drugs and notify her physician
c. neuroleptic malignant syndrome…contact her physician for a transfer to intensive care
d. agranulocytosis…hold her antipsychotic and draw blood for a complete blood count

Answer 18

a. anticholinergic toxicity…check vital signs and prepare to use a cooling blanket stat

Question 19

A patient with schizophrenia tells the nurse “I don’t know, it’s just all the same. You never know. It comes, it goes, it blows away. Get it?” The best response for the nurse to make would be:

a. “Nothing you are saying is clear; you are not making sense.”
b. “Yes, life can be like that sometimes, very confusing.”
c. “Try to organize your thoughts and then tell me again.”
d. “I am having difficulty understanding what you are saying.”

Answer 19

d. “I am having difficulty understanding what you are saying.”

Question 20

A patient with schizophrenia has received typical (first-generation) antipsychotics for a year. His hallucinations are less intrusive, but he remains apathetic, has poverty of thought, cannot work, and is socially isolated. To address these symptoms, the nurse might consult the prescribing health care provider to suggest a change to:

a. haloperidol (Haldol)
b. olanzapine (Zyprexa)
c. diphenhydramine (Benadryl)
d. chlorpromazine (Thorazine)

Answer 20

b. olanzapine (Zyprexa)

Question 21

A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which nursing intervention should receive the highest priority?

a. Conducting passive range-of-motion exercises.
b. Exposing the patient to auditory and visual stimuli.
c. Interacting with the patient as if he is responding.
d. Including the patient in a variety of milieu activities.

Answer 21

a. Conducting passive range-of-motion exercises.

Question 22

A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _________ , and the nurse should _________.

a. a dystonic reaction…administer PRN IM benzotropine (Cogentin).
b. tardive dyskinesia…seek a change in the drug or its dosage.
c. waxy flexibility…continue treatment with antipsychotic drugs.
d. akathisia…administer PRN disphenhydramine (Benadryl) PO

Answer 22

a. a dystonic reaction…administer PRN IM benzotropine (Cogentin).

Question 23

Assuming that each is possible, the nurse who observes W, a client who has received haldol, with his head rotated to one side in a stiffly fixed position with his lower jaw thrust forward and drool coming from his mouth should intervene by

a. obtaining an order to administer Benztropine Mesylate (Cogentin) 1 mg IM
b. Notifying the physician so that the medication can be discontinued immediately
c. administering atropine 2 mg subcutaneously
d. reassuring W that the symptoms will subside if he relaxes

Answer 23

a. obtaining an order to administer Benztropine Mesylate (Cogentin) 1 mg IM

Question 24

A serious medical complication from the antipsychotic clozaril is

a. hepatic failure
b. agranulocytosis
c. athasia
d. hypertensive crisis

Answer 24

b. agranulocytosis

Question 25

A patient with schizophrenia is making up words meaningful only to him. This is termed:

a. echolalia
b. echopraxia
c. neologism
d. anhedonia

Answer 25

c. neologism

Question 26

Patients with schizophrenia are abstract thinkers.

a. True
b. False

Answer 26

b. False

Question 27

J is in the stable II phase of schizophrenia. Which intervention would be most useful at this stage?

a. one-to–one supervision
b. strict limit setting to promote safety
c. enhancing social and self-care skills
d. isolation for acute hallucinations

Answer 27

c. enhancing social and self-care skills

Question 28

A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student’s schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address?

a. losses
b. sleep patterns
c. school activities
d. menstrual flow

Answer 28

a. losses

Question 29

One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:

a. 150 to 102 pounds over a 4-month period. Vital signs: temperature, 96.1° F; pulse, 38 beats/min; blood pressure 64/42 mm Hg.
b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 97.2° F; pulse, 50 beats/min; blood pressure 70/50 mm Hg.
c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 97.6° F; pulse, 60 beats/min; blood pressure 80/66 mm Hg.
d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 98.6° F; pulse, 62 beats/min; blood pressure 74/48 mm Hg.

Answer 29

a. 150 to 102 pounds over a 4-month period. Vital signs: temperature, 96.1° F; pulse, 38 beats/min; blood pressure 64/42 mm Hg.

Question 30

A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, “I will not eat until I lose enough weight to look thin.” Select the best initial nursing diagnosis.

a. Anxiety related to fear of weight gain
b. Disturbed body image related to weight loss
c. Ineffective coping related to lack of conflict resolution skills
d. Imbalanced nutrition: less than body requirements related to self-starvation

Answer 30

d. Imbalanced nutrition: less than body requirements related to self-starvation

Question 31

Anticholinergic (Ach) Toxicity - symptoms

Answer 31

Potentially-life threatening - seen in older adults or those on multiple antipsychotics

• Hyperthermia
• Hot/dry/red skin
• Paralytic ileus
• Agitation
• Delerium
• Fluctuating vital signs
• Tachycardia
• Worsening of psychotic symptoms

Question 32

Neuroleptic malignant syndrome (NMS) - what it is and s/s

Answer 32

Occurs in up to 1% of patients who have taken antipsychotics - can occur w/atypicals as well
Life-threatening medical emergency - fatal in 10% of cases

• Reduced consciousness
• Increased muscle tone (rigidity)
• Autonomic dysfunction (hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling)