Source 2

Question 1

24.Symptoms of withdrawal from opioids for which the nurse should assess
include:
a
.
dilated pupils, tachycardia, elevated blood pressure, and
elation.
b
. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
c
. mood lability, incoordination, fever, and drowsiness.
d
. excessive eating, constipation, and headache.

Answer 1

ANS: B

Question 2

.A hospitalized patient diagnosed with an alcohol abuse disorder believes the
window blinds are snakes trying to get in the room. The patient is anxious,
agitated, and diaphoretic. The nurse can anticipate the health care provider
will prescribe a(n):
a
. narcotic analgesic, such as hydromorphone (Dilaudid).
b
.
sedative, such as lorazepam (Ativan) or chlordiazepoxide
(Librium).
c
.
antipsychotic, such as olanzapine (Zyprexa) or thioridazine
(Mellaril).
d
.
monoamine oxidase inhibitor antidepressant, such as
phenelzine (Nardil).

Answer 2

ANS: B

Question 3

11. An elderly client has met the criteria for a diagnosis of major depressive disorder. The client does not respond to antidepressant medications. Which treatment should a nurse anticipate that the physician would prescribe for this client?
A. Electroconvulsive therapy (ECT)
B. Neuroleptic therapy
C. An antiparkinsonian agent
D. An anxiolytic agent

Answer 3

ANS: A

Question 4

A client diagnosed with neurocognitive disorder due to Alzheimers disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication?
A. Discourage attempts at verbal communication because of increased client frustration.
B. Increase the volume of the nurses communication responses.
C. Verbalize the nurses perception of the implied communication.
D. Encourage the client to communicate by writing.

Answer 4

ANS: C

Question 5

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include:
a.
distracting the patient from self-absorption.
b.
careful unobtrusive observation around the clock.
c.
allowing the patient to spend long periods alone in meditation.
d.
opportunities to assume a leadership role in the therapeutic milieu.

Answer 5

ANS: B

Question 6

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days.Select an appropriate outcome. The patient will:
a.
ask staff for assistance with feeding within 4 days.
b.
drink six servings of a high-calorie, high-protein drink each day.
c.
consistently sit with others for at least 30 minutes at meal time within 1 week.
d.
consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

Answer 6

ANS: B

Question 7

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide?
a.
A high proportion of patients with bipolar disorders are found among creative writers.
b.
A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder.
c.
Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress.
d.
More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.

Answer 7

ANS: B

Question 8

Which dinner menu is best suited for a patient with acute mania?
a.
Spaghetti and meatballs, salad, and a banana
b.
Beef and vegetable stew, a roll, and chocolate pudding
c.
Broiled chicken breast on a roll, an ear of corn, and an apple
d.
Chicken casserole, green beans, and flavored gelatin with whipped cream

Answer 8

ANS: C

Question 9

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patients behavior?
a.
Educate the patient about the proper ways to perform personal hygiene and coordinate clothing.
b.
Continue to monitor and document the patients speech patterns and motor activity.
c.
Ask the health care provider to prescribe an increased dose and frequency of lithium.
d.
Consider the need to check the lithium level. The patient may not be swallowing medications.

Answer 9

ANS: D

Question 10

An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of:
a.
delirium.
c.
amnestic syndrome.
b.
dementia.
d.
Alzheimers disease.

Answer 10

ANS: A

Question 11

Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply.
a.
Impaired level of consciousness
b.
Disorientation to place, time
c.
Wandering attention
d.
Apathy
e.
Agnosia

Answer 11

ANS: A, B, C

Question 12

Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimers disease? Select all that apply.
a.
Acute confusion
b.
Anticipatory grieving
c.
Urinary incontinence
d.
Disturbed sleep pattern
e.
Risk for caregiver role strain

Answer 12

ANS: C, D, E

Question 13

A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse?
a.
Are you having thoughts of suicide?
b.
I am not sure I understand what you are trying to say.
c.
Try to stay hopeful. Things have a way of working out.
d.
Tell me more about what interested you before you became depressed.

Answer 13

ANS: A

Question 14

A nurse is caring for four clients diagnosed with major depressive disorder. When considering each clients belief system, the nurse should conclude which client would potentially be at highest risk for suicide?
A. Roman Catholic
B. Protestant
C. Atheist
D. Muslim

Answer 14

ANS: C

Question 15

A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem?
A. Ineffective coping R/T unresolved anxiety AEB substance abuse
B. Anxiety R/T poor sleep AEB difficulty falling asleep
C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
D. Risk for injury R/T addiction to Librium

Answer 15

ANS: C

Question 16

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse?
A. Alcohol poisoning
B. Cardiovascular accident (CVA)
C. A reaction to disulfiram (Antabuse)
D. A reaction to tannins in the red wine

Answer 16

ANS: C

Question 17

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?
A. By asking directly if the client has ever had a problem with alcohol
B. By holistically assessing the client, using the CIWA scale
C. By using a screening tool such as the CAGE questionnaire
D. By referring the client for physician evaluation

Answer 17

ANS: C

Question 18

Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply.
A. I am easily manipulated and need to work on this prior to caring for these clients.
B. Because of my fathers alcoholism, I need to examine my attitude toward these clients.
C. Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights.
D. Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training.
E. I can fix clients diagnosed with substance use disorders as long as I truly care about them.

Answer 18

ANS: A, B, D