M.H EXAM 4 Flashcards
Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders?
a. Impaired social interaction related to difficulty maintaining relationships
b. Chronic low self-esteem related to excessive negative feedback
c. Deficient fluid volume related to abnormal eating habits
d. Anxiety related to nightmares and repetitive activities
ANS: A
Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.
Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective?
a. plays with one toy for 30 minutes.
b. repeats words spoken by a parent.
c. holds the parent’s hand while walking.
d. spins around and claps hands while walking.
ANS: C
Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone’s hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.
A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to achieve what?
a. integration of self-concept.
b. inpatient treatment for the child.
c. loneliness and increase self-esteem.
d. language and communication skills.
ANS: C
Because of their disruptive behaviors, children diagnosed with attention deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.
What is the nurse’s priority focused assessment for side effects in a child taking methylphenidate for attention deficit hyperactivity disorder (ADHD)?
a. Dystonia, akinesia, and extrapyramidal symptoms
b. Bradycardia and hypotensive episodes
c. Sleep disturbances and weight loss
d. Neuroleptic malignant syndrome
.ANS: C
The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child’s growth and development. The distracters relate to side effects of conventional antipsychotic medications.
What is the nurse’s priority focused assessment for side effects in a child taking methylphenidate for attention deficit hyperactivity disorder (ADHD)?
a. Dystonia, akinesia, and extrapyramidal symptoms
b. Bradycardia and hypotensive episodes
c. Sleep disturbances and weight loss
d. Neuroleptic malignant syndrome
ANS: C
The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child’s growth and development. The distracters relate to side effects of conventional antipsychotic medications.
A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care?
a. Reality therapy
b. Simple restitution
c. Social skills group
d. Insight-oriented group therapy
ANS: C
Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.
The parent of a 6-year-old says, “My child is in constant motion and talks all the time. My child isn’t interested in toys but is out of bed every morning before me.” The child’s behavior is most consistent with diagnostic criteria for which disorder?
a. communication disorder.
b. stereotypic movement disorder.
c. intellectual development disorder.
d. attention deficit hyperactivity disorder (ADHD).
ANS: D
Excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.
ent Needs: Psychosocial Integrity
A child diagnosed with attention deficit hyperactivity disorder (ADHD) had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective?
a. has an improved ability to identify anxiety and use self-control strategies
b. has increased expressiveness in communication with others.
c. shows increased responsiveness to authority figures.
d. engages in cooperative play with other children.
ANS: D
The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child’s aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.
. A child diagnosed with attention deficit hyperactivity disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?
a. CNS stimulants
b. Tricyclic antidepressants
c. Antipsychotics
d. Anxiolytic
ANS: A
CNS stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medicatio
When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse’s best action? a. Instruct the parents to take the aggressive child home.
b. Direct the aggressive child to stop immediately.
c. Call for emergency assistance from other staff.
d. Take the aggressive child to another room.
ANS: D
The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home.
Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, “If my parents loved me, they would work out their problems.” Which nursing diagnosis has the highest priority?
a. Social isolation
b. Decisional conflict
c. Chronic low self-esteem
d. Disturbed personal identity
ANS: A
This child shows difficulty coping with problems associated with the family. Social isolation refers to aloneness that the patient perceives negatively, even when self-imposed. The other options are not supported by data in the scenario.
A nurse works with a child who is sad and irritable because the child’s parents are divorcing. Why is establishing a therapeutic alliance with this child a priority?
a. Therapeutic relationships provide an outlet for tension.
b. Focusing on the strengths increases a person’s self-esteem.
c. Acceptance and trust convey feelings of security to the child.
d. The child should express feelings rather than internalize them.
ANS: C
Trust is frequently an issue because the child may question their trusting relationship with the parents. In this situation, the trust the child once had in parents has been disrupted, reducing feelings of security. The correct answer is the most global response.
A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child’s disorder?
a. has occasional toileting accidents.
b. interrupts or intrudes on others.
c. cries when separated from a parent.
d. continuously rocks in place for 30 minutes.
ANS: D
Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD.
A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, “What should we do?” What is the nurse’s best response?
a. “Ask the teacher to let the child call you at play time.”
b. “Withdraw the child from preschool until maturity increases.”
c. “Remain with your child for the first hour of preschool time.”
d. “Give your child a kiss before you leave the preschool program.”
ANS: D
The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.
The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with what disorder?
a. attention deficit hyperactivity disorder (ADHD).
b. posttraumatic stress disorder (PTSD).
c. communication disorder.
d. an anxiety disorder.
ANS: A
Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.
The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with what disorder?
a. attention deficit hyperactivity disorder (ADHD).
b. posttraumatic stress disorder (PTSD).
c. communication disorder.
d. an anxiety disorder.
ANS: A
Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.
A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse’s best first action?
a. Give notice to the chief administrator at the school regarding the events.
b. Encourage the victimized child to share feelings about the experience.
c. Encourage the victimized child to ignore the bullying behavior.
d. Discuss the events with the aggressive classmate.
ANS: B
The behaviors by the bullying child create emotional pain and present the risk for physical pain. Encouraging the victimized child to share feelings about the experience provides the nurse an opportunity to further assess the situation as well as provide support to the child. The nurse should validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.
A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts. The nurse should monitor for which desired behavior?
a. Increased expressiveness in communication with others
b. Abilities to identify anxiety and implement self-control strategies
c. Improved abilities to participate in cooperative play with other children
d. Tolerates social interactions for short periods without disruption or frustration
ANS: C
The goal is improvement in the child’s hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.
ANS: C
The goal is improvement in the child’s hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.
Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others’ conversations. How should the nurse document these behaviors?
a. Disobedience
b. Hyperactivity
c. Impulsivity
d. Anxiety
ANS: C
These behaviors are most directly related to impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is demonstrated by failure to listen. Defiance is demonstrated by willfully doing what an authority figure has said not to do.
When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses what strategy?
a. guided imagery.
b. talk focused on a specific issue.
c. play and talk about a play activity.
d. group discussion about selected topics.
ANS: C
Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.
When a 5-year-old is disruptive, the nurse says, “You must take a time-out.” The expectation is that the child will do what?
a. go to a quiet room until called for the next activity.
b. slowly count to 20 before returning to the group activity.
c. sit on the edge of the activity until able to regain self-control.
d. sit quietly on the lap of a staff member until able to apologize for the behavior.
ANS: C
Time-out is designed so that staff can be consistent in their interventions. Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self control and reviews the episode with a staff member. Time-out may not require going to a designated room and does not involve special attention such as holding. Counting to 10 or 20 is not sufficient.
Which child demonstrates behaviors indicative of a neurodevelopmental disorder? a. A 4-year-old who stuttered for 3 weeks after the birth of a sibling
b. A 9-month-old who does not eat vegetables and likes to be rocked
c. A 3-month-old who cries after feeding until burped and sucks a thumb
d. A 3-year-old who is mute, passive toward adults, and twirls while walking
ANS: D
Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. ASD is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.
The parent of a child diagnosed with Tourette’s disorder says to the nurse, “I think my child is faking the tics because they come and go.” Which response by the nurse is accurate? a. “Perhaps your child was misdiagnosed.”
b. “Your observation indicates the medication is effective.”
c. “Tics often change frequency or severity. That doesn’t mean they aren’t real.” d. “This finding is unexpected. How have you been administering your child’s medication?”
ANS: C
Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette’s disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.
A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, “My three friends and I got an A on our school science project.” The nurse can assess that the child demonstrating what?
a. resiliency.
b. a passive temperament.
c. at risk for post-traumatic stress disorder (PTSD).
d. intellectualization to deal with problems.
ANS: A
Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills.
Which assessment findings present familial risks for a child to develop a psychiatric disorder? (Select all that apply.)
a. Having a mother diagnosed with schizophrenia
b. Being the oldest child in a family
c. Living with an alcoholic parent
d. Being an only child
e. Living in an urban community
ANS: A, C
Familial risk factors that correlate with child psychiatric disorders include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. Having a parent with a substance abuse problem increases the risk of marital discord. A family history of schizophrenia presents a genetic risk. Being in a middle-income family, living in an urban community, and being an only or oldest child do not represent adversity.
At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? (Select all that apply.)
a. Report the finding to the official child protection social services agency.
b. Educate all members of the family about potential safety risks in online
environments.
c. Talk with the parents about parental controls on the children’s communication devices.
d. Encourage the family to schedule daily time together without communication devices.
e. Obtain the family’s network password and examine online sites family members have visited.
ANS: B, C, D
The nurse’s focus is safety, including online environments. Education and awareness-based approaches are indicated to reduce the risks of potentially harmful behavior, including risks associated with cyberbullying. Parental controls on the children’s devices will support safe
Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family’s network password and an invasion of privacy to inspect sites family members have visited.
A nurse prepares to lead a discussion at a community health center regarding children’s health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? (Select all that apply.)
a. Autism
b. Bullying
c. Mental retardation
d. Autism spectrum disorder
e. Intellectual development disorder
ANS: B, D, E
Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It is important for the nurse to use current terminology.
A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will (Select all that apply.)
a. graduate from high school.
b. live independently in an apartment.
c. independently perform own personal hygiene.
d. obtain employment in a local sheltered workshop.
e. correctly use public buses to travel in the community.
ANS: C, D, E
Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely.
A client has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this client shouts, “They’re all plotting to destroy me. Isn’t that true?” what is the nurse’s most therapeutic response?
a. “Everyone here is trying to help you. No one wants to harm you.”
b. “Feeling that people want to destroy you must be very frightening.”
c. “That is not true. People here are trying to help you if you will let them.”
d. “Staff members are health care professionals who are qualified to help you.”
ANS: B
Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and the tenacity with which the client holds to the delusion. The other options focus on content and provide opportunity for argument.
A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The client states, “I saw two doctors talking in the hall. They were plotting to kill me.” The nurse may correctly assess this behavior using which term?
a. echolalia.
b. paranoia
c. a delusion of infidelity.
d. an auditory hallucination.
ANS: B
Paranoia is an irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you).; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.
A client diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two doctors plotting to kill me.” How does this client perceive the environment? a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre
ANS: B
The client sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the client. Data are not present to support any of the other options.
When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, “I stopped taking those pills. They made me feel like a robot.” What are common side effects the nurse should validate with the client?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose
ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him or her feel like a “robot.” The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the client.
Which hallucination expressed by a client necessitates the nurse to implement safety measures?
a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill me.”
c. “My dead father tells me I am a good person.”
d. “The voices talk only at night when I’m trying to sleep.”
ANS: B
The correct response indicates the client is experiencing paranoia. Paranoia often leads to fearfulness, and the client may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.
A client’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase
ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.
A healthcare provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine
b. Ziprasidone
c. Olanzapine
d. Aripiprazole
ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease. Olanzapine fosters weight gain.
A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The client’s activities of daily living are severely compromised. What will be an appropriate outcome for this client?
a. demonstrates increased interest in the environment by the end of week 1. b. performs self-care activities with coaching by the end of day 3.
c. gradually takes the initiative for self-care by the end of week 2.
d. accepts tube feeding without objection by day 2.
ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.
A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Catatonia
c. Depersonalization
d. Thought withdrawal
ANS: B
Catatonia is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.
A client diagnosed with schizophrenia A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications?
a. Constipation
b. Gynecomastia
c. Visual changes
d. Photosensitivity
ANS: B
FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia (enlargement of the breasts) as well as other changes in sexual function. Men may experience disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing to other aspects of the client’s physical health but are not likely to bother body image.
A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective?
a. Suggest analogies that might apply to a common daily problem.
b. Assign each participant a problem to solve independently and present to the group. c. Ask each client to read aloud a short segment from a book about problem solving. d. Invite participants to come up with solution to getting incorrect change for a purchase.
ANS: D
Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things in a literal manner, is evident in many clients diagnosed with schizophrenia. People who think concretely benefit from concrete situations during education. Finding a solution in order to get incorrect change for a purchase is an example of a concrete situation. Analogies require abstract thinking and insight. Independently solving a problem and presenting it to the group may be intimidating. All participants may or may not be literate.
A nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective?
a. “I will need higher and higher doses of my medication as time goes on.”
b. “I need to store my medication in a cool dark place, such as the refrigerator.” c. “Taking this medication regularly will reduce the severity of my symptoms.” d. “If I run out or stop taking my medication, I will experience withdrawal
symptoms.”
ANS: C
Antipsychotic drugs provide symptom control and allow most clients diagnosed with schizophrenia to live and be treated in the community. Dosing is individually determined. Antipsychotics are not addictive; however, they should be discontinued gradually to minimize a discontinuation syndrome.
A newly admitted client diagnosed with schizophrenia says, “The voices are bothering me. They yell and tell me I am bad. I have got to get away from them.” Select the nurse’s most helpful reply.
a. “Do you hear the voices often?”
b. “Do you have a plan for getting away from the voices?”
c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”
d. “Forget the voices and ask some other clients to play cards with you.”
ANS: C
Staying with a distraught client who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the client hears voices is not particularly relevant at this point. Asking if the client plans to “get away from the voices” is relevant for assessment purposes but is less helpful than offering to stay with the client while encouraging a focus on their discussion. Suggesting playing cards with other clients shifts responsibility for intervention from the nurse to the client and other clients.
A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client’s head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia
ANS: A
Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.
An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?
a. Administer diphenhydramine 50 mg IM from the prn medication administration record.
b. Reassure the client that the symptoms will subside. Practice relaxation exercises with the client.
c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time.
d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.
ANS: A
Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine
A client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the client grimaces and constantly smacks both lips. The client’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette’s syndrome
d. Anticholinergic effects
ANS: B
Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first-generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette’s syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.
A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse’s most therapeutic response? a. “Why are you laughing?”
b. “Please share the joke with me.”
c. “I don’t think I said anything funny.”
d. “You’re laughing. Tell me what’s happening.”
ANS: D
The client is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the client’s laughter) and then elicit the client’s observation. The incorrect options are less useful in eliciting a response: no joke may be involved, “why” questions are difficult to answer, and the client is probably not focusing on what the nurse said in the first place.
The nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
c. Poor personal hygiene
d. Psychomotor agitation
ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia. See relationship to audience response question.
What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms
ANS: A
Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.
A client diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people.” Which problem is evident? a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia
ANS: D
The client’s unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.
A client diagnosed with schizophrenia begins a new prescription for ziprasidone. The client is 5’6’’ and currently weighs 204 lbs. The client has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the client’s plan of care?
a. Skin care techniques
b. Scheduling a colonoscopy
c. Weight management strategies
d. Teaching to limit caffeine intake
NS: C
Ziprasidone is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with second-generation antipsychotic medications. The client is overweight now, so weight management will be especially important. The other interventions may occur in time, but do not have the priority of weight management.
A client diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident?
a. Neologism
b. Idea of reference
c. Thought broadcasting
d. Associative looseness
ANS: D
Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one’s thoughts.
A client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol
b. Olanzapine
c. Chlorpromazine
d. Diphenhydramine
ANS: B
Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.
See relationship to audience response question.
The family of a client diagnosed with schizophrenia is unfamiliar with the illness and family’s role in recovery. Which type of therapy should the nurse recommend?
a. Psychoeducational
b. Psychoanalytic
c. Transactional
d. Family
ANS: A
A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.
A client diagnosed with schizophrenia has been stable for a year; however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says, “My computer is sending out infected radiation beams.” The nurse can correctly assess this information as an indication of what?
a. the need for psychoeducation.
b. medication nonadherence.
c. chronic deterioration.
d. relapse.
ANS: D
Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication nonadherence may not be implicated. Relapse can occur even when the client is taking medication regularly. Psychoeducation is more effective when the client’s symptoms are stable. Chronic deterioration is not the best explanation.
A client diagnosed with schizophrenia begins to talks about “macnabs” hiding in the warehouse at work. The client’s use of “macnabs” should be documented using what term? a. a neologism.
b. concrete thinking.
c. thought insertion.
d. an idea of reference.
ANS: A
A neologism is a newly coined word having special meaning to the client. “Macnabs” is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one’s mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.
A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The client is diaphoretic. What is the nurse’s best analysis and action? a. Agranulocytosis; institute reverse isolation.
b. Tardive dyskinesia; withhold the next dose of medication.
c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat.
ANS: D
Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.
A client receiving risperidone reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The client is diaphoretic. What is the nurse’s best analysis and action? a. Agranulocytosis; institute reverse isolation.
b. Tardive dyskinesia; withhold the next dose of medication.
c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat.
ANS: D
Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
A nurse asks a client diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?” Which response by the client indicates concrete thinking?
a. “The table of contents tells what a book is about.”
b. “You can’t judge a book by looking at the cover.”
c. “Things are not always as they first appear.”
d. “Why are you asking me about books?”
ANS: A
Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the client’s interpretation of proverbs. Concreteness reduces one’s ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking
The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group’s members? a. gain insight into unconscious factors that contribute to their illness.
b. explore situations that trigger hostility and anger.
c. learn to manage delusional thinking.
d. demonstrate improved social skills.
ANS: D
Improved social skills help clients maintain relationships with others. These relationships are important to management of the disorder. Most clients with schizophrenia think concretely, so insight development is unlikely. Not all clients with schizophrenia experience delusions.
A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” What is the nurse’s best initial action?
a. Tell the client, “Facebook is a safe website. You don’t need to worry about Homeland Security.”
b. Tell the client, “You are in a safe place where you will be helped.”
c. Administer a prn dose of an antipsychotic medication.
d. Tell the client, “You don’t need to worry about that.”
ANS: B
The client is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the client is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.
Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility
b. Bizarre behavior
c. Poverty of thought
d. Auditory hallucinations
ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.
. A client insistently states, “I can decipher codes of DNA just by looking at someone.” Which problem is evident?
a. Visual hallucinations
b. Magical thinking
c. Idea of reference
d. Thought insertion
ANS: B
Magical thinking is evident in the client’s appraisal of his own abilities. There is no evidence of the distractors.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
A newly hospitalized client experiencing psychosis says, “Red chair out town board.” Which term should the nurse use to document this finding?
a. Word salad
b. Neologism
c. Anhedonia
d. Echolalia
ANS: A
Word salad is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.
A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.) a. “The importance of taking your medication correctly”
b. “How to complete an application for employment”
c. “How to dress when attending community events”
d. “How to give and receive compliments”
e. “Ways to quit smoking”
ANS: A, E
Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the clients’ physiological well-being. The other topics are also important but are not priority topics
A client diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The client is aloof, suspicious, and says, “Two staff members I saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)
a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation
ANS: A, B
Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the client’s feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses
A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?
a. Increased muscle tension and anxiety
b. Vegetative signs and poor grooming
c. Poor judgment and hyperactivity
d. Cognitive deficits and paranoia
.
ANS: C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania
An older adult client takes multiple medications daily. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What are these findings most characteristic of?
a. delirium.
b. dementia.
c. amnestic syndrome.
d. Alzheimer’s disease.
ANS: A
Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer’s disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2A client with fluctuating levels of awareness, confusion, and disturbed orientation shouts, “Bugs are crawling on my legs. Get them off!” Which problem is the client experiencing? a. Aphasia
b. Dystonia
c. Tactile hallucinations
d. Mnemonic disturbance
ANS: C
The client feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
A client with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, “Someone get these bugs off me.” What is the nurse’s best response?
a. “No bugs are on your legs. You are having hallucinations.”
b. “I will have someone stay here and brush off the bugs for you.”
c. “Try to relax. The crawling sensation will go away sooner if you can relax.” d. “I don’t see any bugs, but I can tell you are frightened. I will stay with y
ANS: D
When hallucinations are present, the nurse should acknowledge the client’s feelings and state the nurse’s perception of reality, but not argue. Staying with the client increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical
safety. Denying the client’s perception without offering help does not support the client emotionally. Telling the client to relax makes the client responsible for self-soothing. Telling the client that someone will brush the bugs away supports the perceptual distortions
What is the priority nursing diagnosis for a client with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Risk for injury related to altered cerebral function, fluctuating levels of
consciousness, disturbed orientation, and misperception of the environment
b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks
c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations
d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations
ANS: A
The physical safety of the client is of highest priority among the diagnoses given. Many opportunities for injury exist when a client misperceives the environment as distorted, threatening, or harmful or when the client exercises poor judgment or when the client’s sensorium is clouded. The other diagnoses may be concerns but are lower priorities
What is the priority intervention for a client diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
a. Distraction using sensory stimulation
b. Careful observation and supervision
c. Avoidance of physical contact
d. Activation of the bed alarm
ANS: B
Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the client will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the client’s safety.
A client diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this client?
a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the client hourly to assess mental status.
d. Keep the client by the nurse’s desk while awake. Provide rest periods in a room with a television on.
ANS: A
A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a client with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
Which assessment finding would be likely for a client experiencing a hallucination? a. The client looks at shadows on a wall and says, “I see scary faces.”
b. The client states, “I feel bugs crawling on my legs and biting me.”
c. The client reports telepathic messages from the television.
d. The client speaks in rhymes.
.
ANS: B
A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations
Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein b-amyloid. Which diagnosis applies? a. Cyclothymia
b. Dementia
c. Delirium
d. Amnesia
ANS: B
The listed cerebral pathophysiologies are all associated with development of dementia.
Which medication prescribed to clients diagnosed with Alzheimer’s disease antagonizes N methyl-D-aspartate (NMDA) channels rather than cholinesterase?
a. Donepezil
b. Rivastigmine
c. Memantine
d. Galantamine
ANS: C
Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer’s disease.
An older adult was stopped by police for driving through a red light. When asked for a driver’s license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia
b. Apraxia
c. Agnosia
d. Anhedonia
.
ANS: C
Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer’s disease is evident?
a. Sundowning
b. Early
c. Middle
d. Late
ANS: C
In the middle stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer’s can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the late stage there is severe cognitive decline along with agraphia, hyperorality, blunting of emotions, visual agnosia, and hypermetamorphosis. Sundowning is not a stage of Alzheimer’s disease.
Consider these phenomena: accumulation of b-amyloid outside the neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. Which health problem corresponds to these events?
a. Huntington’s disease
b. Alzheimer’s disease
c. Parkinson’s disease
d. Vascular dementia
ANS: B
The pathophysiological phenomena described apply to Alzheimer’s disease. Parkinson’s disease is associated with dopamine dysregulation. Huntington’s disease is genetic. Vascular dementia is the consequence of circulatory changes.
A client diagnosed as mild stage Alzheimer’s disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the client cannot remember what to buy. Which nursing diagnosis applies at this time?
a. Self-care deficit
b. Impaired memory
c. Caregiver role strain
d. Adult failure to thrive
ANS: B
Memory impairment begins at the mild stage and progresses in the subsequent stages. This client is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later
A client has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?
a. Assist the client to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the client.
c. Stimulate intellectual function by discussing new topics with the client.
d. Read one story from the newspaper to the client every day.
ANS: A
Clients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the client is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the client. Clients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.
Two clients in a residential care facility are diagnosed with dementia. One shouts to the other, “Move along, you’re blocking the road.” The other client turns, shakes a fist, and shouts, “You’re trying to steal my car.” What is the nurse’s best action?
a. Administer one dose of an antipsychotic medication to both clients.
b. Reinforce reality. Say to the clients, “Walk along in the hall. This is not a traffic intersection.”
c. Separate and distract the clients. Take one to the day room and the other to an activities area.
d. Step between the two clients and say, “Please quiet down. We do not allow violence here.”
ANS: C
Separating and distracting prevents escalation from verbal to physical acting out. Neither client loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening clients is an unsafe action and trying to reinforce reality during an angry outburst will probably not be successful when the clients are cognitively impaired.
An older adult client in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful?
a. Apply the client’s glasses.
b. Place personally meaningful objects in view.
c. Position large clocks and calendars on the wall.
d. Assure that the room is brightly lit but very quiet at all times.
ANS: A
Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.
A client diagnosed with Alzheimer’s disease calls the fire department saying, “My smoke detectors are going off.” Firefighters investigate and discover that the client misinterpreted the telephone ringing. Which problem is this client experiencing?
a. Hyperorality
b. Aphasia
c. Apraxia
d. Agnosia
ANS: D
Agnosia is the inability to recognize familiar objects, parts of one’s body, or one’s own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.
During morning care, a nurse asks a client diagnosed with dementia, “How was your night?” The client replies, “It was lovely. I went out to dinner and a movie with my friend.” Which term applies to the client’s response?
a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium
ANS: B
Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The client’s response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.
A nurse counsels the family of a client diagnosed with Alzheimer’s disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety?
a. Apply a medical alert bracelet to the client.
b. Place locks at the tops of doors.
c. Discourage daytime napping.
d. Obtain a bed with side rails.
ANS: B
Placing door locks at the top of the door makes it more difficult for the client with dementia to unlock the door because the ability to look up and reach upward is diminished. The client will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the client’s sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the client leaves the home, but it does not prevent wandering or assure the client’s safety
What should the goals of care for an older adult client diagnosed with delirium caused by fever and dehydration focus on?
a. returning to premorbid levels of function.
b. identifying stressors negatively affecting self.
c. demonstrating motor responses to noxious stimuli.
d. exerting control over responses to perceptual distortions.
ANS: A
The desired overall goal is that the delirious client will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a client whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a client with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a client with sensorium problems related to delirium.
An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client’s family? a. Label the bathroom door clearly.
b. Take the older adult to the bathroom hourly.
c. Place the older adult in disposable adult briefs.
d. Limit the intake of oral fluids to 1000 mL/day.
ANS: A
The client with moderately severe dementia has memory loss that begins to interfere with activities. This client may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the client in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the client to a urinary tract infection.
An older client diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this client recognizes them when they visit. What is the nurse’s best reply?
a. “Your family member will never again be able to identify you.”
b. “I think that is a question the health care provider should answer.”
c. “One never knows. Consciousness fluctuates in persons with dementia.”
d. “It is disappointing when someone you love no longer recognizes you.”
ANS: D
Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in clients with dementia.
A client diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?
a. Wear large name tags.
b. Focus interaction on familiar topics.
c. Frequently repeat the reorientation strategies.
d. Place large clocks and calendars strategically.
ANS: B
Reorientation may seem like arguing to a client with cognitive deficit and increases the client’s anxiety. Validating, talking with the client about familiar, meaningful things, and reminiscing give meaning to existence both for the client and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because clients with dementia sometimes become more agitated with reorientation
What is the priority need for a client diagnosed with severe, late-stage dementia? a. Promotion of self-care activities
b. Meaningful verbal communication
c. Preventing the client from wandering
d. Maintenance of nutrition and hydration
ANS: D
In severe (late-stage) dementia, the client often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the client is to live. The client is incapable of self-care, ambulation, or verbal communication.
An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the client’s change in mental status?
a. Drug actions and interactions
b. Benzodiazepine withdrawal
c. Hypotensive episodes
d. Renal failure
ANS: A
Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The client takes lorazepam on a prn basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the client’s drug regime, but interactions are more likely the problem.
A hospitalized client diagnosed with delirium misinterprets reality. A client diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The clients will
a. remain safe in the environment.
b. participate actively in self-care.
c. communicate verbally.
d. acknowledge reality.
ANS: A
Risk for injury is the nurse’s priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.
An elderly client is admitted with delirium secondary to a urinary tract infection. The family asks whether the client will ever recover. What is the nurse’s best response?
a. “The health care provider is the best person to answer your question.”
b. “The confusion will probably get better as we treat the infection.”
c. “Unfortunately, delirium is a progressively disabling disorder.”
d. “I will be glad to contact the chaplain to talk with you.”
ANS: B
Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family. .
An elderly adult presents with symptoms of delirium. The family reports, “Everything was fine until yesterday.” What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes
b. Whether the person has experienced any recent losses
c. Whether the person has ingested aged or fermented foods
d. The person’s recent personality characteristics and changes
ANS: A
Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI (monoamine oxidase inhibitor) therapy and depression.
A nurse gives anticipatory guidance to the family of a client diagnosed with mild early stage Alzheimer’s disease. Which problem common to that stage should the nurse address? a. Violent outbursts
b. Emotional disinhibition
c. Communication deficits
d. Inability to feed or bathe self
C
Families should be made aware that the client will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms and problems are usually seen at later stages of the disease.
A client diagnosed with moderate stage Alzheimer’s disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the client’s plan of care. (Select all that apply.)
a. Provide clothing with elastic and hook-and-loop closures.
b. Label clothing with the client’s name and name of the item.
c. Administer antianxiety medication before bathing and dressing.
d. Provide necessary items and direct the client to proceed independently.
e. If the client resists dressing, use distraction and try again after a short interval.
ANS: A, B, E
Providing clothing with elastic and hook-and-loop closures facilitates client independence. Labeling clothing with the client’s name and the name of the item maintains client identity and dignity (provides information if the client has agnosia). When a client resists, it is appropriate to use distraction and try again after a short interval because client’s moods are often labile. The client may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the client to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.
Which assessment findings would the nurse expect in a client experiencing delirium? (Select all that apply.)
a. Impaired level of consciousness
b. Disorientation to place, time
c. Wandering attention
d. Apathy
e. Agnosia
ANS: A, B, C
Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Clients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.
A health care provider recently convicted of Medicare fraud says to a nurse, “Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money.” These statements support what client characteristic?
a. shame.
b. suspiciousness.
c. superficial remorse.
d. lack of guilt feelings.
ANS: D
Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The client’s remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.
Which nursing diagnoses are most applicable for a client diagnosed with severe late stage Alzheimer’s disease? (Select all that apply.)
a. Acute confusion
b. Anticipatory grieving
c. Urinary incontinence
d. Disturbed sleep pattern
e. Risk for caregiver role strain
ANS: C, D, E
The correct answers are consistent with problems frequently identified for clients with late-stage Alzheimer’s disease. Confusion is chronic, not acute. The client’s cognition is too impaired to grieve
Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others?
a. Refer requests and questions related to care to the case manager.
b. Encourage the client to discuss feelings of fear and inferiority.
c. Provide negative reinforcement for acting-out behavior.
d. Ignore, rather than confront, inappropriate behavior.
ANS: A
Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Clients with antisocial personality disorders rarely have feelings of fear and inferiority.
As a nurse prepares to administer medication to a client diagnosed with a borderline personality disorder, the client says, “Just leave it on the table. I’ll take it when I finish combing my hair.” What is the nurse’s best response?
a. Reinforce this assertive action by the client. Leave the medication on the table as requested.
b. Respond to the client, “I’m worried that you might not take it. I’ll come back later.”
c. Say to the client, “I must watch you take the medication. Please take it now.” d. Ask the client, “Why don’t you want to take your medication now?”
ANS: C
The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only for the client’s safety, but also to prevent splitting other staff. “Why” questions are not therapeutic.
What is an appropriate initial outcome for a client diagnosed with a personality disorder who frequently manipulates others?
a. The client will identify when feeling angry.
b. The client will use manipulation only to get legitimate needs met.
c. The client will acknowledge manipulative behavior when it is called to his or her attention.
d. The client will accept fulfillment of his or her requests within an hour rather than immediately.
ANS: C
This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The client would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control.
Consider this comment to three different nurses by a client diagnosed with an antisocial personality disorder, “Another nurse said you don’t do your job right.” Collectively, these interactions can be documented using which term?
a. seductive.
b. detached.
c. manipulative.
d. guilt-producing.
ANS: C
Clients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The client is displaying the opposite of detached behavior. Guilt is not evident in the comments.
Which behavior demonstrated by that a client diagnosed with an antisocial personality disorder most clearly warrants limit setting?
a. Flattering the nurse
b. Lying to other clients
c. Verbal abuse of another client
d. Detached superficiality during counseling
ANS: C
Limits must be set in areas in which the client’s behavior affects the rights of others. Limiting verbal abuse of another client is a priority intervention and particularly relevant when interacting with a client diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.
A client’s spouse filed charges after repeatedly being battered. Which statement by this person supports an antisocial personality disorder?
a. “I have a quick temper, but I can usually keep it under control.”
b. “I’ve done some stupid things in my life, but I’ve learned a lesson.”
c. “I’m feeling terrible about the way my behavior has hurt my family.”
d. “I hit because I am tired of being nagged. My spouse deserves the beating.”
ANS: D
The person with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Persons with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are commonly observed with other psychiatric conditions.
A client diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The client reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed?
a. Benzodiazepine
b. Mood stabilizing medication
c. Monoamine oxidase inhibitor (MAOI)
d. Cholinesterase inhibitor
ANS: B
Mood stabilizing medications have been effective for many clients with borderline personality disorder. Cholinesterase inhibitors are prescribed for persons diagnosed with neurocognitive disorders. Use of anxiolytic medications is not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for clients who are impulsive.
What is the priority nursing diagnosis for a client diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence
b. Risk for self-directed violence
c. Impaired social interaction
d. Ineffective denial
ANS: A
Violence against property, along with threats to harm staff, makes this diagnosis the priority. Clients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When clients with antisocial personality disorders use denial, they use it effectively.
When a client diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration.
b. It respects the client’s wishes, so assertiveness will develop.
c. External controls are necessary due to failure of internal control.
d. Anxiety is reduced when staff assumes responsibility for the client’s behavior.
ANS: C
A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the client is able to behave appropriately.
