Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Acute Psych > Practice Questions - Bank > Flashcards

Practice Questions - Bank Flashcards

You may prefer our related Brainscape-certified flashcards:
Psychology 101 flashcards GRE® Psychology flashcards
1
Q
  1. A geriatric nurse is teaching the client’s family about the possible cause of delirium. Which statement by the nurse is most accurate?
  2. “Taking multiple medications may lead to adverse interactions or toxicity.”
  3. “Age-related cognitive changes may lead to alterations in mental status.”
  4. “Lack of rigorous exercise may lead to decreased cerebral blood flow.”
  5. “Decreased social interaction may lead to profound isolation and psychosis.”
A

1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q
  1. A husband has agreed to admit his spouse, diagnosed with Alzheimer’s disease (AD), to a long-term care facility. He is expressing feelings of guilt and symptoms of depression. Which appropriate nursing diagnosis and subsequent intervention would the nurse document?
  2. Dysfunctional grieving; AD support group
  3. Altered thought process; AD support group
  4. Major depressive episode; psychiatric referral
  5. Caregiver role strain; psychiatric referral
A

1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q
  1. A client diagnosed with vascular neurocognitive disorder (NCD) is discharged to home under the care of his wife. Which information should cause the nurse to question the client’s safety?
  2. His wife works from home in telecommunication.
  3. The client has worked the nightshift his entire career.
  4. His wife has minimal family support.
  5. The client smokes one pack of cigarettes per day.
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q
  1. A client diagnosed with AD can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness?
  2. Stage 4: Mild-to-Moderate Cognitive Decline
  3. Stage 5. Moderate Cognitive Decline
  4. Stage 6. Moderate-to-Severe Cognitive Decline
  5. Stage 7. Severe Cognitive Decline
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q
  1. A client is diagnosed in stage seven of AD. To address the client’s symptoms, which nursing intervention should take priority?
  2. Improve cognitive status by encouraging involvement in social activities.
  3. Decrease social isolation by providing group therapies.
  4. Promote dignity by providing comfort, safety, and self-care measures.
  5. Facilitate communication by providing assistive devices.
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q
  1. Which is the reason for the proliferation of the diagnosis of NCDs?
  2. Increased numbers of neurotransmitters has been implicated in the proliferation of NCD.
  3. Similar symptoms of NCD and depression lead to misdiagnoses, increasing numbers of NCD.
  4. Societal stress contributes to the increase in this diagnosis.
  5. More people now survive into the high-risk period for neurocognitive disorders.
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q
  1. A client diagnosed recently with AD is prescribed donepezil (Aricept). The client’s spouse inquires, “How does this work? Will this cure him?” Which is the appropriate nursing response?
  2. “This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease.”
  3. “This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.”
  4. “This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease.”
  5. “This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.”
A

1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q
  1. Which symptom should a nurse identify that differentiates clients diagnosed with NCDs from clients diagnosed with mood disorders?
  2. Altered sleep
  3. Altered concentration
  4. Impaired memory
  5. Impaired psychomotor activity
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q
  1. A client diagnosed with AD exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate?
  2. Organize a group activity to present reality.
  3. Minimize environmental lighting.
  4. Schedule structured daily routines.
  5. Explain the consequences for aggressive behaviors.
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q
  1. After one week of continuous mental confusion, an older African American client is admitted with a preliminary diagnosis of AD. What should cause the nurse to question this diagnosis?
  2. AD does not typically occur in African American clients.
  3. The symptoms presented are more indicative of Parkinsonism.
  4. AD does not develop suddenly.
  5. There has been no T3- or T4-level evaluation ordered.
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q
  1. A client diagnosed with AD has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority?
  2. Present evidence of objective reality to improve cognition.
  3. Design a bulletin board to represent the current season.
  4. Label the client’s room with name and number.
  5. Assist with bathing and toileting.
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q
  1. A client diagnosed with major NCD is exhibiting behavioral problems on a daily basis. At change of shift, the client’s behavior escalates from pacing to screaming and flailing. Which action should be a nursing priority?
  2. Consult the psychologist regarding behavior-modification techniques.
  3. Medicate the client with prn antianxiety medications.
  4. Assess environmental triggers and potential unmet needs.
  5. Anticipate the behavior and restrain when pacing begins.
A

2 - Medicate the client to avoid injury to self or others.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q
  1. A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. Based on this client’s assessment data, which diagnosis would the nurse expect the physician to assign?
  2. Delirium due to adverse effects of cardiac medications
  3. Vascular neurocognitive disorder
  4. Altered thought processes
  5. Alzheimer’s disease
A

2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q
  1. An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe?
  2. Haloperidol (Haldol)
  3. Donepezil (Aricept)
  4. Diazepam (Valium)
  5. Sertraline (Zoloft)
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q
  1. A client diagnosed with NCD is disoriented and ataxic and wanders. Which is the priority nursing diagnosis?
  2. Disturbed thought processes
  3. Self-care deficit
  4. Risk for injury
  5. Altered health-care maintenance
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q
  1. Which statement accurately differentiates mild NCD from major NCD?
  2. Major NCD involves disorientation that develops suddenly, whereas mild NCD develops more slowly.
  3. Major NCD involves impairment of abstract thinking and judgment, whereas mild NCD does not.
  4. Major NCD criteria requires substantial cognitive decline from a previous level of performance, and mild NCD requires modest decline.
  5. Major NCD criteria requires decline from a previous level of performance in three of the listed domains, and mild NCD requires only one.
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q
  1. Which statement accurately differentiates NCD from pseudodementia (depression)?
  2. NCD has a rapid onset, whereas pseudodementia does not.
  3. NCD symptoms include disorientation to time and place, and pseudodementia does not.
  4. NCD symptoms improve as the day progresses, but symptoms of pseudodementia worsen.
  5. NCD causes decreased appetite, whereas pseudodementia does not.
A

2 - In pseudodementia, symptoms improve as the day progresses, are oriented to time and place, and has rapid onset of symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q
  1. Which of the following conditions have been known to precipitate delirium in some individuals? (Select all that apply.)
  2. Febrile illness
  3. Seizures
  4. Migraine headaches
  5. Herniated brain stem
  6. Temporomandibular joint syndrome
A

1, 2, 3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q
  1. Which of the following medications that have been known to precipitate delirium? (Select all that apply.)
  2. Antineoplastic agents
  3. H2-receptor antagonists
  4. Antihypertensives
  5. Corticosteroids
  6. Lipid-lowering agents
A

1, 2, 3, 4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q
  1. A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?
  2. Assess for medication nonadherance.
  3. Note escalating behaviors and intervene immediately.
  4. Interpret attempts at communication.
  5. Assess triggers for bizarre, inappropriate behaviors.
A

2 - Early intervention may prevent an aggressive response and keep the client and others safe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q
  1. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse’s teaching?
  2. The side effects of medications
  3. Deep breathing techniques to decrease stress
  4. How to make eye contact when communicating
  5. How to be a leader
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q
  1. A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing response?
  2. “Your child has a chemical imbalance of the brain, which leads to altered perceptions.”
  3. “Your child’s hallucinations are caused by medication interactions.”
  4. “Your child has too little serotonin in the brain, causing delusions and hallucinations.”
  5. “Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”
A

1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q
  1. Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response?
  2. “Tell him to stop discussing the voices.”
  3. “Ignore what he is saying, while attempting to discover the underlying cause.”
  4. “Focus on the feelings generated by the hallucinations and present reality.”
  5. “Present objective evidence that the voices are not real.”
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q
  1. A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, “Do you receive special messages from certain sources, such as the television or radio?” The nurse is assessing which potential symptom of this disorder?
  2. Thought insertion
  3. Paranoid delusions
  4. Magical thinking
  5. Delusions of reference
A

4 - A client that believes he/she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward him-or herself

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q
  1. A client diagnosed with schizophrenia spectrum disorder states, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate nursing response?
  2. “Did you take your medicine this morning?”
  3. “You are not going to hell. You are a good person.”
  4. “The voices must sound scary, but the devil is not talking to you. This is part of your illness.”
  5. “The devil only talks to people who are receptive to his influence.”
A

3 - reassure the client while not reinforcing the hallucination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q
  1. A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?
  2. Disturbed sensory perception
  3. Altered thought processes
  4. Risk for violence: directed toward others
  5. Risk for injury
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q
  1. Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder?
  2. Provide neon lights and soft music.
  3. Maintain continual eye contact throughout the interview.
  4. Use therapeutic touch to increase trust and rapport.
  5. Provide personal space to respect the client’s boundaries.
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q
  1. Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder?
  2. Establishing personal contact with family members
  3. Being reliable, honest, and consistent during interactions
  4. Sharing limited personal information
  5. Sitting close to the client to establish rapport
A

2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q
  1. A paranoid client diagnosed with schizophrenia spectrum disorder states, “My psychiatrist is out to get me. I’m sad that the voice is telling me to stop him.” What symptom is the client exhibiting, and what is the nurse’s legal responsibility related to this symptom?
  2. Magical thinking; administer an antipsychotic medication.
  3. Persecutory delusions; orient the client to reality.
  4. Command hallucinations; warn the psychiatrist.
  5. Altered thought processes; call an emergency treatment team meeting.
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q
  1. A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
  2. Tactile hallucinations
  3. Tardive dyskinesia
  4. Restlessness and muscle rigidity
  5. Reports of hearing disturbing voices
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q
  1. A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client’s positive and negative symptoms of schizophrenia?
  2. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.
  3. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.
  4. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
  5. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.
A

2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q
  1. A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?
  2. Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications
  3. Agranulocytosis treated by administration of clozapine (Clozaril)
  4. Extrapyramidal symptoms treated by administration of benztropine (Cogentin)
  5. Tardive dyskinesia treated by discontinuing antipsychotic medications
A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q
  1. After taking chlorpromazine (Thorazine) for 1 month, a client presents to an ED with severe muscle rigidity, tachycardia, and a temperature of 105F (40.5°C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?
  2. Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium)
  3. Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication
  4. Dystonia treated by administering trihexyphenidyl (Artane)
  5. Dystonia treated by administering bromocriptine (Parlodel)
A

1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q
  1. A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize?
  2. Respirations of 22 beats/minute
  3. Weight gain of 8 pounds in 2 months
  4. Temperature of 104°F (40°C)
  5. Excessive salivation
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q
  1. An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?
  2. “Make sure you concentrate on taking slow, deep, cleansing breaths.”
  3. “Watch your diet and try to engage in some regular physical activity.”
  4. “Rise slowly when you change position from lying to sitting or sitting to standing.”
  5. “Wear sunscreen and try to avoid midday sun exposure.”
A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q
  1. A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately?
  2. Sore throat, fever, and malaise
  3. Akathisia and hypersalivation
  4. Akinesia and insomnia
  5. Dry mouth and urinary retention
A

1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q
  1. During an admission assessment, a nurse assesses that a client diagnosed with schizophrenia spectrum disorder has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated?
  2. Haloperidol (Haldol), because it is used only in older patients
  3. Clozapine (Clozaril), because it is incompatible with desipramine
  4. Risperidone (Risperdal), because it exacerbates symptoms of depression
  5. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines
A

4

38
Q
  1. A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis?
  2. The client has experienced impaired reality testing for a 24-hour period.
  3. The client has experienced auditory hallucinations for the past 3 hours.
  4. The client has experienced bizarre behavior for 1 day.
  5. The client has experienced confusion for 3 weeks.
A

2

39
Q
  1. A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client’s symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)?
  2. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not.
  3. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not.
  4. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.
  5. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.
A

3

40
Q
  1. A nurse prepares to assess a client using the Abnormal Involuntary Movement Scale (AIMS). Which side effect of antipsychotic medications led to the use of this assessment tool?
  2. Dystonia
  3. Tardive dyskinesia
  4. Akinesia
  5. Akathisia
A

2

41
Q
  1. Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.)
  2. Group therapy
  3. Medication management
  4. Deterrent therapy
  5. Supportive family therapy
  6. Social skills training
A

1, 2, 4, 5

42
Q
  1. A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would most likely decrease because of the therapeutic effect of this medication? (Select all that apply.)
  2. Somatic delusions
  3. Social isolation
  4. Gustatory hallucinations
  5. Flat affect
  6. Clang associations
A

1, 3, 5

43
Q
  1. Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would a nurse expect to observe during assessment? (Select all that apply.)
  2. Apathy
  3. Social withdrawal
  4. Anhedonia
  5. Auditory hallucinations
  6. Delusions
A

1, 2, 3

44
Q

_________________________ are false sensory perceptions not associated with real external stimuli and may involve any of the five senses.

A

Hallucinations

45
Q
  1. A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?
  2. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure.
  3. Establish room restrictions, because the client’s threat is an attempt to manipulate the staff.
  4. Place client on one-to-one suicide precautions, because specific plans likely lead to attempts.
  5. Call an emergency treatment team meeting, because the client’s threat must be addressed.
A

3

46
Q
  1. In planning care for a suicidal client, which correctly written outcome should be a nurse’s first priority?
  2. The client will not physically harm self.
  3. The client will express hope for the future by day three.
  4. The client will establish a trusting relationship with the nurse.
  5. The client will remain safe during hospital stay.
A

4

47
Q
  1. A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?
  2. Altered communication R/T feelings of worthlessness AEB anhedonia
  3. Social isolation R/T poor self-esteem AEB secluding self in room
  4. Altered thought processes R/T hopelessness AEB persecutory delusions
  5. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
A

2

48
Q
  1. A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse’s priority intervention at this time?
  2. Obtaining an order for locked seclusion until client is no longer suicidal.
  3. Conducting 15-minute checks to ensure safety.
  4. Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
  5. Encouraging client to express feelings related to suicide.
A

3

49
Q
  1. A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis?
  2. The client is disheveled and malodorous.
  3. The client refuses to interact with others and isolates self in room.
  4. The client is unable to feel any pleasure.
  5. The client has maxed-out charge cards and exhibits promiscuous behaviors.
A

4

50
Q
  1. A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse’s priority at this time?
  2. Give the client off-unit privileges as positive reinforcement.
  3. Encourage the client to share mood improvement in group.
  4. Increase the level of this client’s suicide precautions.
  5. Request that the psychiatrist reevaluate the current medication protocol.
A

3

51
Q
  1. A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis?
  2. Thyroid-stimulating hormone (TSH) level of 25 U/mL
  3. Potassium (K+) level of 4.2 mEq/L
  4. Sodium (Na+) level of 140 mEq/L
  5. Calcium (Ca2+) level of 9.5 mg/dL
A

1

52
Q
  1. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?
  2. According to psychoanalytic theory, depression is a result of negative perceptions.
  3. According to object-loss theory, depression is a result of overprotection.
  4. According to learning theory, depression is a result of repeated failures.
  5. According to cognitive theory, depression is a result of anger turned inward.
A

3

53
Q
  1. What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode?
  2. The attention during the assessment is beneficial in decreasing social isolation.
  3. Depression can generate somatic symptoms that can mask actual physical disorders.
  4. Physical health complications are likely to arise from antidepressant therapy.
  5. Depressed clients avoid addressing physical health and ignore medical problems.
A

2

54
Q
  1. A nurse is planning care for a 13 -year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents?
  2. Paroxetine (Paxil)
  3. Sertraline (Zoloft)
  4. Citalopram (Celexa)
  5. Escitalopram (Lexipro)
A

4

55
Q
  1. A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam?
  2. To rule out bipolar disorder
  3. To rule out schizophrenia
  4. To rule out neurocognitive disorder
  5. To rule out personality disorder
A

3 - rule out dementia which can occur as a result of depression

56
Q
  1. An older client has recently been prescribed sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?
  2. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs)
  3. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI)
  4. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI
  5. Serotonin syndrome; possibly caused by ingestion of two different SSRIs
A

4

57
Q
  1. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing response?
  2. “This combination of drugs can lead to delirium tremens.”
  3. “A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.”
  4. “That’s a good idea. There have been good results with the combination of these two drugs.”
  5. “The only disadvantage would be the exorbitant cost of the MAOI.”
A

2

58
Q
  1. A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client?
  2. Zung Depression Scale
  3. Hamilton Depression Rating Scale
  4. Beck Depression Inventory
  5. AIMS Depression Rating Scale
A

2 - most widely used clinician-administered scales is the Hamilton Depression Rating Scale. Zung and Beck are self-rating scales.

59
Q
  1. The severity of depressive symptoms in the postpartum period varies from a feeling of the “blues,” to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms?
  2. Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions)
  3. Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)
  4. Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia)
  5. Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)
A

2

60
Q
  1. A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of “automatic thoughts.” Which client statement is evidence of the “automatic thought” of discounting positives?
  2. “It’s all my fault for trusting him.”
  3. “I don’t play games. I never win.”
  4. “She never visits because she thinks I don’t care.”
  5. “I don’t have a green thumb. Any old fool can grow a rose.”
A

4

61
Q
  1. A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.)
  2. Sad mood on most days
  3. Mood rating of 2 out of 10 for the past 6 months
  4. Labile mood
  5. Sad mood for the past 3 years after spouse’s death
  6. Pressured speech when communicating
A

1, 4

62
Q
  1. An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.)
  2. Gender differences in social opportunities that occur with age
  3. Drastic temperature and barometric pressure changes
  4. A seasonal increase in social interactions
  5. Variations in serotonergic functioning
  6. Inaccessibility of resources for dealing with life stressors
A

2, 3, 4

63
Q
  1. A nursing instructor is teaching about the new DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD). Which of the following information should the instructor include? (Select all that apply.)
  2. Symptoms include verbal rages or physical aggression toward people or property.
  3. Temper outbursts must be present in at least two settings (at home, at school, or with peers).
  4. DMDD is characterized by severe recurrent temper outbursts.
  5. The temper outbursts are manifested only behaviorally.
  6. Symptoms of DMDD must be present for 18 or more months to meet diagnostic criteria.
A

1, 2, 3

64
Q 
26. Order the depressive disorders and their predominant affective symptoms according to level of severity.
\_\_\_\_\_\_\_\_ Dysthymic disorder (pessimistic outlook, low self-esteem)
\_\_\_\_\_\_\_\_ Grief (feelings of anger, anxiety, guilt, helplessness)
\_\_\_\_\_\_\_\_ Major depressive episode (despair, worthlessness, flat affect, apathy, anhedonia)
\_\_\_\_\_\_\_\_ Transient depression (sadness, dejection, feeling downhearted, having “the blues”)
A

Major depressive episode, grief, transient depression, dysthymic

65
Q

_______________________ is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world.

A

Mood

66
Q
  1. A highly agitated client paces the unit and states, “I could buy and sell this place.” The client’s mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client’s behavior?
  2. “Rates mood 8/10. Exhibiting looseness of association. Euphoric.”
  3. “Mood euthymic. Exhibiting magical thinking. Restless.”
  4. “Mood labile. Exhibiting delusions of reference. Hyperactive.”
  5. “Agitated and pacing. Exhibiting grandiosity. Mood labile.”
A

4

67
Q
  1. A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?
  2. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
  3. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
  4. Risk for suicide R/T powerlessness AEB insomnia and anorexia
  5. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
A

2

68
Q
  1. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit?

Client Outcomes:

  1. Maintains nutritional status
  2. Interacts appropriately with peers
  3. Remains free from injury
  4. Sleeps 6 to 8 hours a night
  5. 2, 1, 3, 4
  6. 4, 1, 2, 3
  7. 3, 1, 4, 2
  8. 1, 4, 2, 3
A

3

69
Q
  1. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize?
  2. Risk for suicide R/T hopelessness
  3. Anxiety: severe R/T hyperactivity
  4. Imbalanced nutrition: less than body requirements R/T refusal to eat
  5. Dysfunctional grieving R/T loss of employment
A

1

70
Q
  1. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe?
  2. Sertraline (Zoloft)
  3. Valproic acid (Depakote)
  4. Trazodone (Desyrel)
  5. Paroxetine (Paxil)
A

2

71
Q
  1. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa order. Which is the appropriate nursing response?
  2. “Zyprexa in combination with Eskalith cures manic symptoms.”
  3. “Zyprexa prevents extrapyramidal side effects.”
  4. “Zyprexa increases the effectiveness of the immune system.”
  5. “Zyprexa calms hyperactivity until the Eskalith takes effect.”
A

4

72
Q
  1. A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?
  2. “That’s strange. Weight loss is the typical pattern.”
  3. “What have you been eating? Weight gain is not usually associated with lithium.”
  4. “Weight gain is a common, but troubling, side effect.”
  5. “Weight gain only occurs during the first month of treatment with this drug.”
A

3

73
Q
  1. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
  2. Symptoms indicate consumption of foods high in tyramine.
  3. Symptoms indicate lithium carbonate discontinuation syndrome.
  4. Symptoms indicate the development of lithium carbonate tolerance.
  5. Symptoms indicate lithium carbonate toxicity.
A

4

74
Q
  1. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?
  2. “Treatment is compromised when clients can’t sleep.”
  3. “Treatment is compromised when irritability interferes with social interactions.”
  4. “Treatment is compromised when clients have no insight into their problems.”
  5. “Treatment is compromised when clients choose not to take their medications.”
A

4

75
Q
  1. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 lb by the end of the week?”
  2. Provide client with high-calorie finger foods throughout the day.
  3. Accompany client to cafeteria to encourage adequate dietary consumption.
  4. Initiate total parenteral nutrition to meet dietary needs.
  5. Teach the importance of a varied diet to meet nutritional needs.
A

1

76
Q
  1. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?
  2. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania.
  3. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania.
  4. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.
  5. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.
A

3

77
Q
  1. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate?
  2. Increase the dosage of fluoxetine.
  3. Discontinue the fluoxetine and rethink the client’s diagnosis.
  4. Order benztropine (Cogentin) to address extrapyramidal symptoms.
  5. Order olanzapine (Zyprexa) to address altered thoughts.
A

2

78
Q
  1. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder?
  2. Medication adherence
  3. Empowerment of the consumer
  4. Total absence of symptoms
  5. Improved psychosocial relationships
A

2

79
Q
  1. Which of the following instructions regarding lithium therapy should be included in a nurse’s discharge teaching? (Select all that apply.)
  2. Avoid excessive use of beverages containing caffeine.
  3. Maintain a consistent sodium intake.
  4. Consume at least 2,500 to 3,000 mL of fluid per day.
  5. Restrict sodium content.
  6. Restrict fluids to 1,500 mL per day.
A

1, 2, 3

80
Q
  1. A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.)
  2. Symptoms lasting for a minimum of two years
  3. Numerous periods with manic symptoms
  4. Possible comorbid diagnosis of a delusional disorder
  5. Symptoms cause clinically significant impairment in important areas of functioning
  6. Depressive symptoms that do not meet the criteria for major depressive episode
A

4, 5

81
Q
  1. Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.)
  2. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.
  3. Children are naturally active, energetic, and spontaneous.
  4. Neurotransmitter levels vary considerably in accordance with age.
  5. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.
  6. Genetic predisposition is not a reliable diagnostic determinant.
A

1, 2

82
Q

______________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

A

Mania

83
Q
  1. A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, “I’m such a terrible mother. What did I do to cause this?” Which nursing response is most appropriate?
  2. “Researchers really don’t know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored.”
  3. “Poor parenting doesn’t cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control.”
  4. “Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father.”
  5. “Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?”
A

2

84
Q
  1. In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome?
  2. The client will communicate all needs verbally by discharge.
  3. The client will participate with peers in a team sport by day four.
  4. The client will establish trust with at least one caregiver by day five.
  5. The client will perform most self-care tasks independently.
A

3

85
Q
  1. After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss?
  2. The pharmacological action of Ritalin causes a decrease in appetite.
  3. Hyperactivity seen in ADHD causes increased caloric expenditure.
  4. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased.
  5. Increased ability to concentrate allows the client to focus on activities rather than food.
A

1

86
Q
  1. A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client’s plan of care?
  2. Encourage and reward peer contact.
  3. Provide consistent caregivers.
  4. Provide a variety of safe daily activities.
  5. Maintain close physical contact throughout the day.
A

2

87
Q
  1. A preschool child diagnosed with autistic spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate?
  2. Place client in restraints until the aggression subsides.
  3. Sedate the client with neuroleptic medications.
  4. Hold client’s head steady and apply a helmet.
  5. Distract the client with a variety of games and puzzles.
A

3

88
Q
  1. A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis?
  2. The client will name own body parts as separate from others by day five.
  3. The client will establish a means of communicating personal needs by discharge.
  4. The client will initiate social interactions with caregivers by day four.
  5. The client will not harm self or others by discharge.
A

1

89
Q
  1. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child’s ADHD. Which nursing response best addresses the mother’s concern?
  2. “The physician will probably switch from Ritalin to a central nervous system stimulant.”
  3. “The physician may prescribe an antihistamine with the Ritalin to improve effectiveness.”
  4. “Your child has probably developed a tolerance to Ritalin and may need a higher dosage.”
  5. “Your child has developed sensitivity to Ritalin and may be exhibiting an allergy.”
A

3

90
Q
  1. Which of the following findings should a nurse identify that would contribute to a client’s development of ADHD? (Select all that apply.)
  2. The client’s father was a smoker.
  3. The client was born 7 weeks premature.
  4. The client is lactose intolerant.
  5. The client has a sibling diagnosed with ADHD.
  6. The client has been diagnosed with dyslexia.
A

2, 4

Acute Psych (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions