TEST 2: Schizophrenia, Other Psychoses, and Cognitive Disorders

Question 1

The Client with Paranoid Schizophrenia
1. A newly admitted client describes her mission in life as one of saving her son by eliminating
the “provocative sluts” of the world. There are several attractive young women on the unit. What
should the nurse do first?
1. Ask the client for her definition of “provocative sluts.”
2. Ask the young female clients on the unit to dress less provocatively.
3. Ask the client to discuss her concerns in the next group session.
4. Ask the client to inform the staff if she has negative thoughts about other clients.

Answer 1

The Client with Paranoid Schizophrenia
1. 4. It is critical for the nurse to ensure the safety of others by knowing who the client might think
needs elimination. Asking the client to explain what she means or discuss her concerns at the group
session are possible interventions for later in the client’s hospital stay. Wearing appropriate clothing
while hospitalized is generally a unit expectation for all clients.
CN: Psychosocial integrity; CL: Synthesize

Question 2

2. A young client diagnosed with paranoid schizophrenia is talking with the nurse. “You know,
   when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I’d like to
   get out and do things again.” What is the best initial response by the nurse?
3. “With whom do you want to do things?”
   “What activities did you enjoy in the past?”
4. “What kind of transportation do you use?”
5. “How much money can you spend?”

Answer 2

2. 2. Knowing the client’s interests is the best place to begin to help the client resocialize.
      Knowing with whom the client wishes to socialize, what transportation she has, or how much
      spending money she has may be relevant questions, but should be asked after the question concerning
      what activities the client enjoyed in the past.
      CN: Psychosocial integrity; CL: Synthesize

Question 3

3. A client is becoming agitated during a discussion group. She states, “I know that all of you hate
   me.” She leaves the group and goes to her room. Which action by the nurse is most therapeutic for the
   client?
4. After group, ask the client to talk to the nurse about her concerns.
5. Ask the client to return to group and share her feelings.
6. Explain to group members about the client’s problems.
7. Ask the group members to apologize to the client individually.

Answer 3

3. 1. It is appropriate to talk alone with this client about her feelings. A suspicious client is
      unlikely to agree to talk about feelings in a group. It is a violation of the client’s privacy to reveal a
      client’s problems to group members. The other clients in the group have no reason to apologize, and
      the nurse should not ask them to do so.
      CN: Psychosocial integrity; CL: Synthesize

Question 4

4. A client who is neatly dressed and clutching a leather briefcase tightly in his arms scans the
   adult inpatient unit on his arrival at the hospital and backs away from the window. The client requests
   that the nurse move away from the window. The nurse recognizes that doing as the client requested is
   contraindicated for which of the following reasons?
5. The action will make the client feel that the nurse is humoring him.
6. The action indicates nonverbal agreement with the client’s false ideas.
7. The client will then think that he will have his way when he wishes.
8. The nurse will be demonstrating a lack of composure over the situation.

Answer 4

4. 2. The nurse’s nonverbal behavior, moving away from the window as the client requests,
      indicates agreement with the client’s false ideas. The client’s behavior is likely to be reinforced if the
      nurse takes steps to agree with the false ideas the client holds.
      CN: Psychosocial integrity; CL: Synthesize

Question 5

5. A client reports having thoughts of being followed by foreign agents who are after his secret
   papers. Which response by the nurse is most appropriate when responding to the client’s disturbed
   thought process?
6. “I don’t see any foreign agents.”
   “I think these thoughts are frightening to you.”
7. “I don’t know what you mean.”
8. “I’d like you to come to group with me right now.”

Answer 5

5. 2. The client’s disturbed thought process likely reflects this client’s paranoid delusions. The
      nurse should acknowledge that the thoughts are frightening the client. Telling the client the nurse does
      not see any foreign agents is an appropriate nursing response if the client is having disturbed visual
      sensory perception and is having visual hallucinations. Telling the client the nurse does not
      understand what the client means is an appropriate response if the client has impaired verbal
      communication. Suggesting that a client participate in group activities would be appropriate if the
      client had a nursing diagnosis of social isolation and was staying in his room.
      CN: Psychosocial integrity; CL: Synthesize

Question 6

6. Police bring a client to the emergency department after she threatens to kill her ex-husband.
   She states emphatically, “The police should bring him in, not me. He’s paranoid about my dating and
   has been stalking me for weeks. He’s probably off his medicines. His case manager and the police
   won’t do anything.” In which order should the following nursing actions be done from first to last?1. Ask about the marital problems leading to the divorce.
7. Assess the client’s risk for harm to self and others.
8. Obtain the name of her ex-husband’s case manager.
9. Interview the client about her current needs and situation.

Answer 6

6.
2. Assess the client’s risk for harm to self and others.4. Interview the client about her current needs and situation.
3. Obtain the name of her ex-husband’s case manager.
1. Ask about the marital problems leading to the divorce.
The nurse should first assess the client’s risk for harm, especially because the client could direct
her anger toward her ex-husband or the nurse. Then it is important to know more about her current
situation and her immediate needs. Obtaining information from the ex-husband’s case manager might
help clarify the risk of harm to the client. Problems leading to the divorce are less important than the
situation following the divorce.
CN: Management of care; CL: Synthesize

Question 7

7. A client who has been stabilized on medications for several months is at the clinic for a
   medication check. During a conversation with the nurse, the client suddenly jumps up, begins pacing,
   and wrings her hands. In what order should the nurse do the following interventions from first to last?
8. Walk with the client to help decrease her anxiety.
9. Discuss productive ways to solve her problems causing anxiety.
10. Share observations about her anxiety-related behaviors.
11. Ask the client about the sources of her anxiety.

Answer 7

7.
1. Walk with the client to help decrease her anxiety.
3. Share observations about her anxiety-related behaviors.
4. Ask the client about the sources of her anxiety.
2. Discuss productive ways to solve her problems causing anxiety.
The nurse should first walk with the client to reduce her anxiety because the client must be at a
mild level of anxiety before learning can occur. Sharing observations with the client conveys a sense
of caring. Later, the nurse can help the client connect the anxiety-related behaviors to her feelings of
anxiety. Once the client can identify the source of her anxiety, she can talk about solutions.
CN: Management of care; CL: Synthesize

Question 8

8. A client is receiving haloperidol decanoate (Haldol decanoate). He has stiff muscles,
   restlessness, and internal jumpiness. The client has all of the following medications prescribed as
   needed. Which one would be most appropriate for the nurse to administer to decrease the client’s
   symptoms?
9. Lorazepam (Ativan)
10. Benztropine mesylate (Cogentin)3. Trazodone (Desyrel)
11. Olanzapine (Zyprexa)

Answer 8

8. 2. The reported symptoms are signs of extrapyramidal side effects (EPSE). The medication of
      choice is benztropine, an antiparkinson medicine. Lorazepam is an antianxiety agent. Trazodone is an
      antidepressant used to enhance sleep. Olanzapine is an antipsychotic medication that could aggravate
      the extrapyramidal side effects.
      CN: Pharmacological and parental therapies; CL: Synthesize

Question 9

9. The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4
   days ago are attending a family psychoeducation group in the hospital. Which of the following
   statements by the mother indicates that she understands her daughter’s illness and management?
10. “I know that I’ll have to do everything for my daughter when she comes home.”
    “Tasks as simple as getting out of bed and showering in the morning may be difficult for her.”
11. “I know that visits from her friends at home should be discouraged for a while.”
12. “She won’t experience a relapse as long as she takes her prescribed medication.”

Answer 9

9. 2. Clients with paranoid schizophrenia experience alterations in thought resulting in
      introspection, confusion, and distraction from external reality. Simple tasks that require concentration
      and effort, including activities involving self-care, may be difficult for the client, especially during
      the acute phase of the illness. However, the mother should not need to do everything for her daughter.
      Rather, the mother should encourage the daughter to do things for herself with guidance. Visits fromfriends should be discussed with the client, and the client should be encouraged to visit with friends
      to minimize the risk of social isolation. Although relapse typically occurs with medication
      noncompliance, vulnerability to stress, a low threshold for stress, the number of stresses, and the
      client’s lack of adaptive coping behaviors contribute to relapse.
      CN: Safety and infection control; CL: Evaluate

Question 10

10. While conducting a home visit for a client diagnosed with paranoid schizophrenia discharged
    1 week ago, the client’s mother tearfully states, “I can hardly sleep because I’m so worried about my
    daughter. I’m afraid to leave her alone in the house. What if something should happen while I’m
    gone?” Which of the following problems related to the caregiver would be the most inclusive one for
    the nurse to incorporate into the client’s plan of care?
11. Caregiver role strain.
12. Anxiety.
13. Fear.
14. Disturbed sleep pattern.

Answer 10

10. 1. The nurse recognizes the mother’s feelings of being overwhelmed with the issues
       concerning the management of her daughter at home as caregiver role strain. Anxiety, fear, and sleep
       disturbances all contribute to caregiver role strain. The nurse should help the mother elicit the support
       of other family members or friends, continue with psychoeducation, and help the family connect with
       the Alliance for the Mentally Ill for support, reassurance, and education.
       CN: Psychosocial integrity; CL: Analyze

Question 11

11. When conducting a mental status examination with a newly admitted client who has an Axis I
    diagnosis of paranoid schizophrenia, the client states, “I’m being followed; it’s not safe. They’re
    monitoring my every move.” In which of the following areas of the mental status examination should
    the nurse document this information?
12. Thought content.
13. Quality of speech.
14. Insight.
15. Judgment.

Answer 11

11. 1. The client is voicing paranoid delusions of being followed and monitored. Presence of
       delusions is described in the area of thought content in the mental status examination. The speech
       section would typically include documentation of disturbances in speech or pressured speech. In the
       insight section, the nurse would document information reflecting a lack of insight—for example,
       statements such as “I don’t have a problem.” In the judgment section, the nurse would document
       information reflecting a lack of judgment—for example, poor choices such as buying a gun for self-
       protection.
       CN: Psychosocial integrity; CL: Analyze

Question 12

12. The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband’s
    admission and states to the nurse, “Why isn’t he eating? He’s still talking about his food being
    poisoned.” Which of the following appraisals by the nurse is most accurate?
13. The wife’s inquiry is reasonable.
14. Education about her husband’s medications is needed.
15. Her expectations of her husband are realistic.
16. An increase in the client’s medication is indicated.

Answer 12

12. 2. For the client with paranoid schizophrenia, 2 days on medication is too short a time for
       improvement to be seen. Therefore, the nurse evaluates the client’s wife as needing education or
       knowledge about paranoid schizophrenia, the course of the illness, and medications. Expecting an
       absence of delusions by the end of the client’s second day of hospitalization is unrealistic. Rather, the
       nurse would reasonably expect delusions to decrease, disappearing by 5 to 9 days of hospitalization.
       The wife’s inquiry is not reasonable because not enough time has elapsed to evaluate the effectiveness
       of treatment. An increase in the client’s medication would be unreasonable because not enough time
       has elapsed to evaluate the effectiveness of the medication. Generally, a time frame of 5 to 7 days is
       needed before the effectiveness of medications can be determined.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 13

13. A client states that she hears God’s voice telling her that she has sinned and needs to punish
    herself? Which response by the nurse is most important?
14. “How do you think you will be punished?”
    “Please tell staff when you think you need to punish yourself.”
15. “What exactly do you think you have done to be punished?”
16. “Let’s talk about your strengths.”

Answer 13

13. 2. The client is at risk for harming herself because of the command auditory hallucinations. It
       is most important for the staff to know if she currently thinks she needs to punish herself. Then it is
       important to know how she thinks she might punish herself. Knowing what she thinks she has done is
       relevant for changing her negative thinking. Focusing on her strengths would help improve her self-
       esteem.
       CN: Psychosocial integrity; CL: Synthesize

Question 14

14. When developing the plan of care for a client who is staying in his room because he
    perceives that staff want to harm him, which of the following outcomes of care planning is most
    realistic?1. Within 2 days, the client will complete activities of daily living.
15. Within 3 days, the client will participate in recreation with other clients.
16. Within 4 days, the client will demonstrate an absence of verbal aggression.
17. Within 5 days, the client will seek out staff to talk about feelings.

Answer 14

14. 4. The client is exhibiting suspiciousness of and a lack of trust in the staff, not aggression.
       Seeking out staff indicates the development of trust and decreased suspiciousness. Although
       completing activities of daily living and participating in recreation with other clients are important,
       the major problem presented is related to the client’s isolation and perception of being harmed—not,
       for example, showering, hygiene, or other clients.
       CN: Psychosocial integrity; CL: Create

Question 15

15. A client diagnosed with paranoid schizophrenia is still withdrawn, unkempt, and unmotivated
    to get out of bed. A mental health aide asks the nurse why the client is this way after being on
    fluphenazine 10 mg for 7 days. The nurse should tell the health aide:
    “Fluphenazine is most effective with the positive symptoms of schizophrenia.”
16. “The client will be less withdrawn and unmotivated when the fluphenazine takes effect.”
17. “The client’s fluphenazine dose probably needs to be increased again.”
18. “Lack of motivation is a common side effect of fluphenazine.”

Answer 15

15. 1. Fluphenazine is most effective with the positive symptoms of schizophrenia. The client’s
       symptoms reflect the negative symptoms. Fluphenazine generally is effective in 3 to 7 days for the
       positive symptoms. An increased dose or longer time on fluphenazine will not help the negative
       symptoms of being withdrawn and unmotivated.
       CN: Pharmacological and parental therapies; CL: Apply

Question 16

16. A pregnant client in her third trimester is started on chlorpromazine 25 mg four times daily.
    Which of the following instructions is most important for the nurse to include in the client’s teaching
    plan?
17. “Don’t drive because there’s a possibility of seizures occurring.”
    “Avoid going out in the sun without a sunscreen with a sun protection factor of 25.”
18. “Stop the medication immediately if constipation occurs.”
19. “Tell your doctor if you experience an increase in blood pressure.”

Answer 16

16. 2. Chlorpromazine is a low-potency antipsychotic that is likely to cause sun-sensitive skin.
       Therefore, the client needs instructions about using sunscreen with a sun protection factor of 25 or
       higher. Typically, chlorpromazine is not associated with an increased risk of seizures. Although
       constipation is a common adverse effect of this drug, it can be managed with diet, fluids, and
       exercise. The drug does not need to be discontinued. Chlorpromazine is associated with postural
       hypotension, not hypertension. Additionally, if postural hypotension occurs, safety measures, such as
       changing positions slowly and dangling the feet before arising, not stopping the drug, are instituted.
       CN: Pharmacological and parenteral therapies; CL: Create

Question 17

17. A client reports that men in blue clothes keep looking in her window and talking about her.
    Which of the following responses by the nurse is most appropriate?
    “Those men are groundskeepers. They’re talking about their work, not you.”
18. “Don’t take things so personally. Not everyone who is talking is talking about you.”
19. “Let’s not pay attention to the men. Let’s play cards instead.”
20. “I’ll close the drapes so you can’t see the men.”

Answer 17

17. 1. The nurse needs to present the reality of the situation. By explaining that the men are
       groundskeepers and probably talking about work, the nurse is reinforcing reality to counter the client’s
       illusion (misinterpretation of reality). Additionally, this response voices doubt in the client’s paranoid
       interpretation. Telling the client not to take things personally is flippant and judgmental. Telling the
       client to not pay attention to the men fails to address the client’s misinterpretations and
       misperceptions. Closing the drapes so that the client doesn’t see the men ignores the client’s
       misperceptions and misinterpretation.
       CN: Psychosocial integrity; CL: Synthesize

Question 18

18. When preparing the teaching plan for a client who is to start clozapine (Clozaril), which of
    the following is crucial to include?
19. Description of akathisia and drug-induced parkinsonism.
20. Measures to relieve episodes of diarrhea.
21. The importance of reporting insomnia.
22. An emphasis on the need for weekly blood tests.

Answer 18

18. 4. Clozapine is associated with agranulocytosis. Therefore, the nurse must instruct the client
       about the need for weekly blood tests to monitor for this adverse effect. Akathisia and drug-induced
       parkinsonism are associated with high-potency antipsychotics. These effects are not common with this
       atypical antipsychotic agent. Constipation and sedation may occur with this drug.
       CN: Pharmacological and parenteral therapies; CL: Create

Question 19

19. A client is sitting in the corner of the dayroom cocking his head to one side as if he hears
    something, but no one is nearby. The nurse suspects he is having auditory hallucinations. Which of the
    following questions should the nurse ask first?
20. “Are you seeing someone other than me?”
    “What are you hearing right now?”
21. “What is going on with you right now?”
22. “Do you want to go to the recreation room?”

Answer 19

19. 2. Before intervening with the client experiencing hallucinations, the nurse must validate what
       the client is experiencing. Asking the client what he hears right now accomplishes this. Asking about
       seeing someone near the client would be appropriate to validate visual hallucinations. Asking the
       client about what is going on may be helpful. However, the question is too general to validate that the
       client is experiencing auditory hallucinations. Asking the client if he wants to go to the recreation
       room might be appropriate after the nurse has validated what the client is experiencing.
       CN: Psychosocial integrity; CL: Synthesize

Question 20

20. A client who is newly diagnosed with paranoid schizophrenia tells the nurse, “The aliens are
    telling me that I’m defective and need to be eliminated.” Which of the following responses by the
    nurse is most appropriate initially?
21. “I know those voices are real to you, but I don’t hear them.”
22. “You are having hallucinations as a result of your illness.”“I want you to agree to tell staff when you hear these voices.”
23. “Your medications will help control these voices you are hearing.”

Answer 20

20. 3. The client may act on command hallucinations and harm himself or others. Therefore, the
       staff need to know when the client is hearing such commands, to ensure safety first. Telling the client
       that the voices are real but that the nurse doesn’t hear them would be an appropriate response later in
       the client’s hospitalization when the client’s safety is no longer an issue because antipsychotics are
       beginning to take effect. Telling the client that the hallucinations are part of the illness or that
       medications will help control the voices would be appropriate once the client has developed some
       insight into the symptoms of the illness.
       CN: Safety and infection control; CL: Synthesize

Question 21

21. An outpatient client who has a history of paranoid schizophrenia and chronic alcohol
    dependency has been taking risperidone (Risperdal) for several months. She reports that she stopped
    drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under
    her skin. Which of the following factors should the nurse incorporate into the plan of care when
    explaining the tactile hallucinations?
22. Alcohol intoxication.
23. Ineffectiveness of risperidone.
24. Alcohol withdrawal.
25. Interaction of alcohol and risperidone.

Answer 21

21. 3. Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia.
       Therefore, the nurse should explain that these hallucinations are the result of withdrawal from
       alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has
       little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia.
       Alcohol and risperidone have an additive effect, not one of causing hallucinations.
       CN: Physiological adaptation; CL: Analyze

Question 22

22. A client with a long history of paranoid schizophrenia is readmitted voluntarily after missing
    his last two injections of haloperidol decanoate (Haldol Decanoate). He reports, “I’m not sleeping
    much, and my friend says I smell from not showering. God is telling me to protect myself from others.
    My parents are sick and tired of me and my illness. They wish I were dead.” Which of the following
    admission notes by the nurse contains assumptions and potentially false accusations? Select all that
    apply.
23. Client has been noncompliant with his medications, causing decreased sleep and activities of
    daily living, increased auditory hallucinations, and paranoid delusions about his parents
    harming him.
24. Client has missed two injections of Haldol Decanoate and was admitted voluntarily. He
    reports he has decreased sleep and showering and that he hears God’s voice telling him to
    protect himself from others. He stated, “My parents are sick and tired of me and my illness.
    They wish I were dead.”
25. Client has missed two doses of Haldol Decanoate. He’s not sleeping and showering. Has a
    strained relationship with his parents and delusions that they want him dead. Voluntary
    admission to restart Haldol Decanoate.
26. Client admitted for noncompliance with Haldol Decanoate injections, sleep disturbance, poor
    hygiene, auditory hallucinations, and suspiciousness of his parents. Needs to be monitored for
    suicidal and homicidal ideation.
27. Client admitted because of hallucinations and delusions. His parents may be abusing him. He
    states he has not taken his medications for 2 days.

Answer 22

22. 1, 3, 4, 5. Documentation provided in option 2 is the most factual and without conclusions or
    assumptions. Stating that the client was noncompliant with medications is not the only cause of
    decreased sleep and activities of daily living or increased delusions and hallucinations. Also, the
    client did not say that his parents wanted to harm him directly. Stating that the client’s relationship
    with his parents is strained is an assumption, even if he did indeed state that they wanted him dead.
    The client does not state a wish to be dead or harm others, although further assessment would be
    necessary. Documenting that his parents may be abusing him makes an assumption, although the nurse
    should further assess for this possibility.
    CN: Management of care; CL: Evaluate

Question 23

23. A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and
    wringing his hands. He states that another client is out to get him. Then he says, “Protect me, select
    me, reject me.” The nurse should next:
24. Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol).
25. Place the client in temporary seclusion before he has a chance to hurt others.
26. Call the primary health care provider for a prescription for restraints.
27. Ask the other clients to leave the immediate area.

Answer 23

23. 1. The client’s anxiety as reflected in rapid pacing and clang associations is rising as a result
       of his paranoid delusions. Administering the Ativan and Haldol will help the anxiety and delusions.
       The client is not threatening others at this point, so seclusion, restraints, and asking clients to leave
       the area is not necessary.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 24

24. In a family education group for those who have relatives with paranoid schizophrenia, which
    of the following comments indicates the need for further teaching about symptom management?
25. “When the clients get overwhelmed, it’s best if they spend some time in their room.”
    “The more we push the clients to spend time with friends, the more their voices decrease.”3. “Until we get the clients up and going, they seem to have no motivation to do anything.”
26. “We still have to remind the clients that we don’t hear the voices they do.”

Answer 24

24. 2. Pushing a suspicious client into social situations is likely to increase anxiety, which
       increases, not decreases, the hallucinations. The statement about spending some time alone if the
       client is overwhelmed indicates awareness and understanding of how to intervene when the client is
       exposed to stress. The statement about lack of motivation indicates awareness and understanding of
       avolition. The statement about reminding the client that the family doesn’t hear the voices indicates
       awareness and understanding of the client’s hallucinations.
       CN: Psychosocial integrity; CL: Evaluate

Question 25

25. A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects? “If I eat too many fruits, I'll get constipated.” 2. “I need to take the medicine with food to avoid nausea.” 3. “I have to get up slowly so I don't get dizzy.” 4. “Sometimes I have to push myself because I'm sleepy.”

Answer 25

25. 1. Clozapine is the one atypical antipsychotic associated with severe anticholinergic adverse effects such as constipation. Consuming fruits would not be the cause of the client's constipation. The client should take clozapine with food to avoid nausea. Getting up slowly indicates that the client understands that postural hypotension may occur with clozapine. The statement about sleepiness indicates that the client understands that sedation may occur with this drug. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 26

26. Which of the following statements indicates increased insight by the client about her newly diagnosed paranoid schizophrenia being stabilized on medications? 1. “Now that the voices are gone, I can decrease my medicines.” 2. “I would feel better if I knew there wasn't poison in my food.” 3. “Since I feel better, I know I can restart school next week.” 4. “The voices go away when I tell them to, except if I'm really nervous.”

Answer 26

26. 4. The statement about the voices occurring if the client is nervous reflects awareness that stress and anxiety can increase the positive symptoms of schizophrenia. Decreasing the medications because the voices are gone reveals a lack of awareness about the need for the medications to control the client's symptoms. Stating that there is still poison in her food demonstrates a lack of insight into the client's delusions. Restarting school in a week reflects an unrealistic expectation for a client who is newly diagnosed and being stabilized on medications. CN: Psychosocial integrity; CL: Evaluate

Question 27

27. A client who is suspicious of others including staff is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care? 1. Helping the client feel safe and accepted. 2. Introducing the client to other clients. 3. Giving the client information about the program. 4. Providing the client with clean, comfortable clothes.

Answer 27

27. 1. The initial priority for this client is to help her overcome suspiciousness of others,including staff, and thereby feel safe and accepted. Introducing the client to others, giving the client information about the program, and providing clean clothes are important, but these are of lower priority than helping the client feel safe and accepted. CN: Psychosocial integrity; CL: Create

Question 28

28. The parent of a young adult client diagnosed with paranoid schizophrenia is asking questions about his son's antipsychotic medication, ziprasidone. Which of the following statements by the father reflects a need for further teaching? 1. “If he experiences restlessness or muscle stiffness, he should tell the doctor.” “I should give him benztropine to help prevent constipation from the ziprasidone.” 3. “If he becomes dizzy, I'll make sure he doesn't drive.” 4. “The ziprasidone should help him be more motivated and less withdrawn.”

Answer 28

28. 2. Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the primary health care provider. Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 29

The Client with Other Types of Schizophrenia and Psychotic Disorders 29. The nurse is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention? 1. Very high temperature. 2. Muscular rigidity. 3. Tremors. 4. Altered consciousness.

Answer 29

The Client with Other Types of Schizophrenia and Psychotic Disorders 29. 1. Muscular rigidity, tremors, and altered consciousness are symptoms of other movement disorders as well as NMS, such as extrapyramidal side effects (EPSEs) (dystonias and drug-induced parkinsonism). High temperature is unique to NMS, particularly when seen with the other three symptoms. NMS is potentially fatal and needs immediate attention. CN: Reduction of risk potential; CL: Analyze

Question 30

30. A client diagnosed with undifferentiated schizophrenia gained 50 lb (22.7 kg) in 6 months while taking olanzapine. After seeing her psychiatrist who changed the medication to ziprasidone, the client tells the nurse, “I don't want to take this ziprasidone either. I can't gain any more weight.” Which response by the nurse is most appropriate for this client? “Ziprasidone causes less weight gain than the other atypical antipsychotics.” 2. “We can give it to you as an injection rather than in capsule form.” 3. “Abnormal movements are not as common with ziprasidone.” 4. “You can take it just before bedtime, so you won't need a snack.”

Answer 30

30. 1. Most clients experience less weight gain when taking ziprasidone. Although ziprasidone can be administered intramuscularly, it can be used only on an as needed basis by this route. Ziprasidone has fewer extrapyramidal side effects (EPSE), but that is not this client's major concern. Ziprasidone is better absorbed when taken with food, so a bedtime snack is needed. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 31

31. As hospital-based care has become more oriented to crisis intervention, criteria for admission to the hospital have also changed. Which clients have priority for admission to an acute care facility? Select all that apply. 1. Clients who live alone. 2. Clients who are acutely psychotic. 3. Clients who are acutely depressed. 4. Clients who are dangerous to self or others. 5. Clients who are not sleeping and have a lack of appetite. 6. Clients who are not complying with medication regimens

Answer 31

31. 2, 4. Safety issues, including protection of the client and others, are the priorities for admission. Acute psychosis commonly involves issues of safety. Living alone is not a sufficient reason to be admitted to a health care facility. Depression, insomnia, lack of appetite, and noncompliance are important issues but not sufficient for admission unless combined with one of the other criteria. CN: Management of care; CL: Analyze

Question 32

32. A 79-year-old woman is brought to the outpatient clinic by her daughter for a routine medication evaluation. The daughter reports that her mother is quite stable and has no adverse effects from the risperidone (Risperdal) she is taking. Then the daughter says, “I just think my mother could be even better if she was on a larger dosage. My son takes 1 mg of Risperdal every day and my mother is only on 0.5 mg.” What is the most helpful response by the nurse? 1. “Maybe your son is sicker than your mother is.” 2. “We could increase your mother's dosage if you want.” “Older clients generally need only one-third to one-half the dose of younger people.” 4. “I'm not seeing any symptoms of illness in your mother. Let's wait until the next visit.”

Answer 32

32. 3. Elderly clients are typically on lower dosages of antipsychotic medications due to the metabolic changes of aging. Comparing dosages is not relevant. Each client is unique in metabolizing medications. Changing medication dosages is based on an assessment of illness symptoms and the adverse effect profile, not on family preferences. Urging the daughter to wait discounts her concerns and gives no rationale for waiting. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 33

33. At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine (Zyprexa) even though it controls his symptoms of schizophrenia better than other medications. “I have gained 20 lb (9.1 kg) already. I can't stand anymore.” Which response by the nurse is most appropriate? 1. “I don't think you look fat; why do you think so?”“I can help you with a diet and exercise plan to keep your weight down.” 3. “You can be switched to another medicine.” 4. “Your weight gain will level off if you stay on the medication 3 more months.”

Answer 33

33. 2. Helping the client control his weight is the most appropriate approach. The nurse's contradiction of the client's statement is inappropriate. Most atypical antipsychotics cause weight gain and are not a solution to the weight gain. There is little evidence that weight gain from taking olanzapine decreases with time. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 34

34. A client diagnosed with schizophrenia is being switched to risperidone long-acting injection (Risperdal Consta). He is told that he will remain on his oral dose of risperidone (Risperdal) daily for approximately 1 month. The client says, “I didn't have to take pills when I was on fluphenazine decanoate (Prolixin Decanoate/Modecate) shots in the past.” The nurse should tell the client: 1. “Taking fluphenazine orally and by injection would not be as effective as the injection alone.” 2. “Risperdal Consta is less potent than Prolixin Decanoate/Modecate.” 3. “The doctor didn't believe you would take both the pills and Prolixin Decanoate/Modecate.” 4. “Risperdal Consta initially takes a little longer to reach the ideal blood level.”

Answer 34

34. 4. Achieving a therapeutic blood level is a slower process with risperidone long-acting injection. Oral fluphenazine does not decrease the effectiveness of the intramuscular version and might increase the incidence of adverse effects. There is no evidence that the potency of the two medications is significantly different. Blaming the client for noncompliance with these two medications is inappropriate. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 35

35. One of the important aspects of the client's rights is the right to treatment in the least restrictive environment. The nurse observes this principle when making which decisions? Select all that apply. 1. Referring a client to a group home or supervised apartment living. 2. Releasing client information to a primary care physician or a relative. 3. Placing a client in seclusion or restraints. 4. Respecting the client's right to accept or refuse treatment. 5. Placing a committed client in a daily outpatient group or a weekly self-help group.

Answer 35

35. 1, 3, 5. Group homes, apartment programs, seclusion, restraints, day treatment programs, and self-help groups all involve degrees of restriction and supervision. Releasing information about the client is governed by legislation and rules of confidentiality. Accepting or refusing treatment is governed by laws related to informed consent. CN: Management of care; CL: Analyze

Question 36

36. A client has been perceiving her roommate's stuffed animal as her own dog at home. The nurse determines that this misperception of reality (illusion) is improving when the client makes which of the following statements? “Jan's stuffed dog looks somewhat like my dog, Trixie.” 2. “Jan's dog and my dog could be twins.” 3. “I wish Jan hadn't had my dog stuffed.” 4. “I guess Jan needs a dog as much as I do.”

Answer 36

36. 1. Recognition by the client that there is a difference between the stuffed animal and her live dog indicates that the client perceives the reality of the situation. Stating that the stuffed animal and the client's dog could be twins reflects the client's continued misperception of reality, thinking that the stuffed animal and her dog are one and the same. Stating that she wishes her dog hadn't been stuffed reflects her continued misperception of reality. Stating that the roommate needs a dog as much as she does is unrelated to the client's perception or misperception of reality. CN: Psychosocial integrity; CL: Evaluate

Question 37

37. When asked about her stresses before admission, an anxious client stares blankly at the nurse and mutters unintelligibly. Which of the following descriptions of the client's behaviors should the nurse document in the client's chart? 1. “Client cannot answer any questions asked at this time.” 2. “Client is uncooperative during the admission procedure, refusing to answer any questions.” “Client responded to questions with a blank look and incomprehensible mumble.” 4. “Client stared at the wall when asked questions and was disoriented and incoherent.”

Answer 37

37. 3. The nurse must be objective in documenting the client's behavior, recording exactly what the client did or did not say or do in a particular situation. Recording that the client could not answer any questions, was uncooperative and refused to answer questions, or was disoriented and incoherent is not described and is a subjective interpretation on the nurse's part. CN: Management of care CL: Create

Question 38

38. When planning care for a client with schizophrenia who lacks motivation to shower and dress, which of the following outcomes should the nurse expect the client to achieve by the end of 4 days? 1. Verbalize the need to shower and dress herself. 2. Recognize the need to shower and dress herself. 3. Explain reasons for showering and dressing herself. 4. Perform showering and dressing for herself.

Answer 38

38. 4. By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client's ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking. CN: Management of care; CL: Create

Question 39

39. A client diagnosed with schizophrenia is brought to the hospital from a group home where he became agitated, threw a chair at another client, and has been refusing medication for 8 weeks. Theclient exhibits a flat affect, is not caring for his hygiene, and has become increasingly withdrawn and asocial. The primary health care provider prescribes treatment with risperidone (Risperdal) to improve the client's negative and positive symptoms of schizophrenia. When evaluating the drug's effectiveness on the client's negative symptoms, the nurse should expect improvement in which of the following? 1. Apathy, affect, social isolation. 2. Agitation, delusions, hallucinations. 3. Hostility, ideas of reference, tangential speech. 4. Aggression, bizarre behavior, illusions.

Answer 39

39. 1. When determining the effectiveness of risperidone, the nurse would expect improvement in the client's negative symptoms of apathy, flat affect, and social withdrawal. Delusions, hallucinations, illusions, and ideas of reference are positive symptoms of schizophrenia. Agitation, hostility, and aggression are the result of the positive symptoms. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 40

40. A 77-year-old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because “I'm so worried about everything.” Her son says that she has heart failure and chronic schizophrenia. “In addition to all of her heart medicines, she is on aripiprazole (Abilify), which was increased to 30 mg by her family doctor 3 days ago.” In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which of the following? Select all that apply. 1. The qualifications of the client's primary care provider. 2. The client's symptoms of schizophrenia. 3. The dose of aripiprazole. 4. The client's symptoms of heart failure. 5. The client's relationship with her son.

Answer 40

40. 2, 3, 4. The client's symptoms are likely to be adverse effects of aripiprazole, especially at the reported dose. The normal adult dose is 5 to 10 mg. The elderly client commonly needs a lower dose compared with other adults. The anxiety and sleep disturbance could be symptoms of schizophrenia or medication adverse effects. A holistic approach would include assessing the client's heart failure. Questioning the qualifications of the family doctor is unproductive. There are no indications of problems in the client's relationship with her son.CN: Pharmacological and parenteral therapies; CL: Analyze

Question 41

41. A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as indicating which of the following? 1. Delusion, requiring further assessment. 2. Unusual reaction to clozapine. 3. Expected adverse effect of clozapine. 4. Unresolved symptom of schizophrenia.

Answer 41

41. 3. Sialorrhea, excessive salivation, is commonly associated with clozapine therapy. The client can use a washcloth to wipe the saliva instead of spitting. It is an expected adverse effect of the drug, not a delusion, an unusual reaction, or an unresolved symptom of schizophrenia. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 42

42. The client with an Axis I diagnosis of schizophrenia, undifferentiated type, is acutely psychotic and exhibits religious delusions and hallucinations, loose associations, and concrete thinking. When the nurse offers the client her medication, the client states, “I don't need that. God will heal me.” The nurse should respond to the client by saying: 1. “God helps those who help themselves.” 2. “God wants you to take your medicine.” “God is important in your life, but the medicine will help you too.” 4. “This medicine will help clear your thoughts and decrease anxiety.”

Answer 42

42. 3. Stating that God is important in the client's life recognizes the client's cognitive and perceptual disturbances and level of anxiety and acknowledges the client's message in a respectful and neutral manner, while adding that the medicine also will help, clearly and directly states the need for medication. Stating, “God helps those who help themselves” challenges the client. Stating, “God wants you to take your medicine” is deceitful. Stating, “Medicine will help clear your thinking and decrease anxiety” would be helpful to the client later when she is less acutely psychotic and anxious. CN: Psychosocial integrity; CL: Apply

Question 43

43. The nurse hands the medication cup to a client who is psychotic and exhibiting concrete thinking, and tells the client to take his medicine. The client takes the cup, holds it in hand, and stares at it. Which of the following should the nurse do next? 1. Tell the client to put the medicine in the mouth and swallow it with some water. 2. Instruct the client to sit in the dayroom and wait for the nurse to assist him. 3. Ask another staff member to stay with the client until the client takes the medication. 4. Say nothing and wait for the client to put the medication in the mouth and swallow it.

Answer 43

43. 1. The nurse instructs the client clearly and directly to put the medication in the mouth and then to swallow it with some water. Clear, step-by-step directions assist the client to process what the nurse is saying. Telling the client to sit in the dayroom and wait, asking another staff member to stay with the client, or saying nothing is not helpful. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 44

44. Which action by the nurse is likely to increase the anxiety and suspiciousness of a client who is delusional? 1. Informing the client of schedule changes. 2. Whispering with others where the client can observe. 3. Telling the client gently that the nurse does not share the client's view. 4. Inviting the client to join in leisure activities.

Answer 44

44. 2. Whispering and laughing with another person where the client can see or observe the nurse but not hear the conversation increases the client's anxiety and suspiciousness. Therefore, this action should be avoided. Informing the client of schedule changes, telling the client gently that the nurse does not share the client's interpretation of an event, and inviting the client to participate in leisure activities help the client to decrease anxiety and suspiciousness and to focus on actual or realistic events. CN: Psychosocial integrity; CL: Synthesize

Question 45

45. A client with undifferentiated schizophrenia tells the nurse that he doesn't go out much because he doesn't have anywhere to go and he doesn't know anyone in the apartment where he's staying. Which of the following actions is most beneficial for the client at this time? 1. Encouraging him to call his family to visit more often. 2. Making an appointment for the client to see the nurse daily for 2 weeks. 3. Thinking about the need for rehospitalization for the client. 4. Arranging for the client to attend day treatment at the clinic.

Answer 45

45. 4. Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as he is capable of need to be fostered, including getting out and developing new friendships. Arranging for participation in day treatment is most beneficial at this time. Family visits and daily nursing visits do not encourage the client to do this. Making an appointment for 2 weeks later puts the client's needs off. Lack of social relationships is not a sufficient reason for rehospitalization. CN: Psychosocial integrity; CL: Synthesize

Question 46

46. The plan of care for an outpatient client with chronic undifferentiated schizophrenia (CUS) includes risperidone (Risperdal) therapy. The nurse prepares to administer this drug based on the understanding of which of the following? 1. The positive symptoms of CUS are usually more prominent than the negative symptoms. 2. Agranulocytosis is less of a risk with risperidone therapy than with clozapine (Clozaril). 3. Traditional antipsychotics help with negative symptoms, but not as well as Risperdal does. 4. Risperidone is less expensive than traditional antipsychotics.

Answer 46

46. 2. With CUS, negative symptoms are more prominent. Therefore, risperidone is given to help control negative symptoms. Negative symptoms do not respond to traditional antipsychotics such as Haldol or Thorazine. Agranulocytosis is commonly associated with clozapine (Clozaril). Because it is a newer drug, risperidone usually is more expensive than traditional antipsychotics. CN: Pharmacological and parenteral therapies; CL: Apply

Question 47

47. A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Abilify) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply. 1. Headaches that will subside in a few weeks. 2. Transient mild anxiety. 3. Insomnia. 4. Torticollis. 5. Pill rolling movements.

Answer 47

47. 1, 2, 3. Headaches, transient anxiety, and insomnia are the most common adverse effects of aripiprazole. Torticollis and pill rolling are more common with the older antipsychotics. CN: Pharmacological and parenteral therapies; CL: Create

Question 48

48. A newly admitted client with an acute exacerbation of psychotic symptoms of chronic undifferentiated schizophrenia (CUS) is having trouble deciding whether to live in a group home or a supervised apartment. When caring for this client, which of the following activities is most appropriate for the nurse to ask the client to do initially? 1. List the pros and cons of each housing option. 2. Choose between apple and orange juice for breakfast. 3. Identify why the client cannot live in an unsupervised apartment. 4. Decide which staff member the client would like to have today.

Answer 48

48. 2. The client is in an acute psychotic state and cannot process complex decisions or explaincomplex situations. Therefore, the nurse would focus on decision making involving simple choices. Listing the pros and cons of each housing option and identifying why the client cannot live in an unsupervised apartment involve complex decision-making skills. Deciding which staff member to have today is a difficult and threatening decision for a client who is psychotic. CN: Management of care; CL: Synthesize

Question 49

49. An outpatient client who has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature of 103°F (39.4°C), and trouble breathing on day 3. The nurse interprets these findings as indicating which of the following? 1. Neuroleptic malignant syndrome. 2. Tardive dyskinesia. 3. Extrapyramidal adverse effects.4. Drug-induced parkinsonism.

Answer 49

49. 1. The client is exhibiting hallmark signs and symptoms of life-threatening neuroleptic malignant syndrome induced by the haloperidol. Tardive dyskinesia usually occurs later in treatment, typically months to years later. Extrapyramidal adverse effects (dystonia, akathisia) and drug-induced parkinsonism, although common, are not life threatening. CN: Reduction of risk potential; CL: Analyze

Question 50

50. A client with chronic undifferentiated schizophrenia (CUS) reports doing very little all day except sleeping and eating. The nurse should: 1. Have three meals per day brought in to increase the amount of time the client spends out of bed. 2. Ask a relative to call the client at least 10 times a day to decrease the sleeping. 3. Help the client set up a daily activity schedule to include setting a wake-up alarm. 4. Arrange for the client to move to a group home with structured activities.

Answer 50

50. 3. The client with CUS needs more structure every day to improve functioning. Therefore, helping the client to set up a daily activity schedule is most appropriate. However, a group home is not necessary. The client is already eating. Having meals brought in would increase the client's dependence, not his activity level. Asking a relative to call the client 10 times per day is unrealistic given the typical daily responsibilities of a healthy relative. CN: Psychosocial integrity; CL: Synthesize

Question 51

51. The nurse notes that a client sitting in a chair has not gotten up in 1 hour. The client does not respond to verbal directions, and her arm has been extended over the armrest for 30 minutes. Which of the following should the nurse do next? 1. Assist the client out of the chair to lead her back to bed. 2. Give PRN-prescribed doses of haloperidol (Haldol) and lorazepam (Ativan). 3. Ask the client to describe what she is experiencing right now. 4. Sit quietly with the client until she begins to respond.

Answer 51

51. 2. The client is exhibiting catatonic behavior, an acutely serious result of severe anxiety and psychosis. In this situation, the nurse needs to administer the PRN-prescribed doses of haloperidol and lorazepam; they can be given together safely. Assisting the client out of the chair to go back to bed or sitting quietly until the client responds ignores the seriousness of the client's condition. It is unlikely that the client can describe what is being experienced. CN: Psychosocial integrity; CL: Synthesize

Question 52

52. What is the most appropriate long-term goal for an outpatient client with chronic undifferentiated schizophrenia (CUS) who has been withdrawn from friends and family for 3 weeks? 1. Calling the client's mother once a day. 2. Attending day therapy three times a week. 3. Allowing two friends to visit every day. 4. Remaining out of bed for 10 hours a day.

Answer 52

52. 2. Attending day therapy three times per week is a long-term goal that will show the most progress in overcoming withdrawal. The client's calling his mother is a first step in getting out of a severe withdrawal. Allowing two friends to visit every day would be appropriate if the client is successful with calling his mother once a day. Insufficient information is presented in the scenario to indicate that excessive sleep is a problem. CN: Psychosocial integrity; CL: Create

Question 53

53. For the client with catatonic behaviors, which of the following should the nurse use to determine that the medication administered as needed has been most effective in the long term? 1. The client can move all extremities occasionally. 2. The client walks with the nurse to the client's room. 3. The client responds to verbal directions to eat. 4. The client initiates simple activities without directions.

Answer 53

53. 4. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors. Moving all extremities occasionally, walking with the nurse to the client's room, and responding to verbal directions to eat represent single steps toward the client initiating her own actions. CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 54

54. The mother of a client with chronic undifferentiated schizophrenia (CUS) calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. “She was doing so well for months. I don't know what's wrong. I'm worried.” Which of the following responses by the nurse is most appropriate? 1. “Maybe she's just mad at you. Did you have an argument?” “She may have stopped taking her medications. I'll check on her.” 3. “Don't worry about this. It happens sometimes.” 4. “Go over to her apartment and see what's going on.”

Answer 54

54. 2. Noncompliance with medications is common in the client with CUS. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms. CN: Management of care; CL: Synthesize

Question 55

55. During a home visit, the nurse discovers that the client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The nurse interprets these findings to indicate that the client needs which of the following? 1. A sleep aid. 2. A clinic appointment. 3. An increase in medication. 4. Immediate medical evaluation.

Answer 55

55. 4. The client is exhibiting symptoms of becoming catatonic and unable to care for himself, andneeds immediate evaluation and possible hospitalization. A sleep aid is not sufficient to treat this client. The client's worsening condition dictates action without waiting for a clinic appointment. An increase in medication may be indicated, but hospitalization is required first for safety. CN: Management of care; CL: Analyze

Question 56

56. A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed has had an increase in manic symptoms in the past week. The psychiatrist prescribes a valproic acid blood level to be drawn at once. The nurse understands the rationale for this prescription as which of the following? 1. All clients taking valproic acid need periodic valproic acid levels drawn. 2. Fluoxetine can decrease the effectiveness of the valproic acid. 3. A decrease in the level of valproic acid could explain the increase in manic symptoms. 4. The valproic acid level is needed before a short course of lorazepam for agitation can be prescribed

Answer 56

56. 3. Valproic acid is commonly used to treat manic symptoms. Therefore, a decrease in the valproic acid level could explain the increase in manic symptoms. Periodic determinations of the valproic acid level are necessary to determine the effectiveness of the drug. However, the stat nature of the specimen to be drawn indicates an immediate problem. Fluoxetine is not known to decrease the effectiveness of valproic acid. The valproic acid level is not needed before beginning a short course of therapy with lorazepam. CN: Pharmacological and parenteral therapies; CL: Apply

Question 57

57. A 22-year-old client is being admitted with a diagnosis of brief psychotic disorder. Two weeks ago, his girlfriend broke off their engagement and canceled the wedding. Given the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised, criteria for this disorder, the nurse should expect to find which data during the interview with the client? 1. Current treatment for pneumonia. 2. Regular use of alcohol or marijuana. 3. Evidence of delusions or hallucinations. 4. A history of chronic depression.

Answer 57

57. 3. According to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised, a diagnosis of brief psychotic disorder is made when the client exhibits delusions, hallucinations, and disorganized speech or behaviors in the absence of a mood disorder, substance-induced disorder, or general medical condition. CN: Reduction of risk potential; CL: Analyze

Question 58

58. A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, “He is fine except for this irrational belief that we will remarry.” When collaborating with the health care provider about a plan of care, which of the following will be most effective for the client at this time? 1. A prescription for olanzapine (Zyprexa) 10 mg daily. 2. A joint session with the client and his ex-wife. 3. A prescription for fluoxetine (Prozac) 20 mg every morning. 4. Referral to an outpatient therapist.

Answer 58

58. 4. Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated. CN: Management of care; CL: Synthesize

Question 59

Clients and Families Affected by Chronic Mental Illnesses 59. When working with clients who are experiencing chronic mental illnesses, which of the following should the nurse expect to be generally the least necessary for this client population? 1. Community-based treatment programs. 2. Psychosocial rehabilitation. 3. Employment opportunities. 4. Custodial care in long-term hospitals.

Answer 59

Clients and Families Affected by Chronic Mental Illnesses 59. 4. During necessary periods of hospitalization, active treatment, rather than custodial care, is needed. Among the more common needs of the chronically mentally ill are community-based treatment programs, psychosocial rehabilitation programs, and employment opportunities. CN: Management of care; CL: Apply

Question 60

60. The nurse is planning care for a group of clients who are chronically mentally ill. Which of the following strategies is likely to be the least beneficial for the client population? 1. Teaching independent living skills. 2. Assisting clients with living arrangements. 3. Helping clients in insight-oriented therapy. 4. Linking clients with community resources.

Answer 60

60. 3. Insight-oriented therapy is less beneficial for this client population. The nurse's role in a psychosocial rehabilitation program involves teaching the client to live independently by using interpersonal skills and community resources. CN: Psychosocial integrity; CL: Apply

Question 61

61. A nurse working at an outpatient mental health center primarily with chronically mentally ill clients receives a telephone call from the mother of a client who lives at home. The mother reports that the client has not been taking her medication and now is refusing to go to the sheltered workshop where she has worked for the past year. What should the nurse do first? 1. Call the director of the workshop for information about the client. 2. Reserve an inpatient bed in preparation for the client's admission. 3. Ask to speak to the client directly on the phone. 4. Make an appointment for the client to see the doctor.

Answer 61

61. 3. The first thing that the nurse should do is to speak with the client on the phone and question her about perceptions or reasons that are interfering with her going to the sheltered workshop. This conveys that the nurse is interested and willing to help the client. The nurse should call the director of the workshop for information only if the nurse receives the client's permission. Making preparations for the client's admission is inappropriate and would not be done until the client's needs have been assessed and it is determined that the client requires hospitalization. Making an appointment with the doctor is inappropriate until the nurse has assessed the client's needs. CN: Management of care; CL: Synthesize

Question 62

62. A nurse is teaching the families of clients with chronic mental illnesses about causes of relapse and rehospitalization. What should the nurse include as the primary cause? 1. Loss of family support. 2. Noncompliance with medications. 3. Sudden changes in medications. 4. Nonattendance at treatment programs.

Answer 62

62. 2. Noncompliance with medications is documented as the primary cause of relapse. Although loss of family support, sudden changes in medications, and nonattendance at treatment programs may contribute to relapse, these factors are not as significant as medication noncompliance as causes of relapse. CN: Psychosocial integrity; CL: Analyze

Question 63

63. The director of a workshop program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started at the workshop. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which of the following interventions is most appropriate? 1. Make a home visit and tell the client that if he does not return to the workshop, he will lose his place there. 2. Ask the director to assign the client to another work group when he returns to the workshop. 3. Make an appointment to meet the client at the mental health center and ask him about the situation. 4. Arrange for the placement of the client in a skill-training program.

Answer 63

63. 3. The most therapeutic action at this time is for the nurse to make an appointment with the client at the mental health center to explore his feelings and behavior. Doing so acknowledges the client's importance and makes him a partner in resolving the problem. The nurse needs to determine what is going on in the situation first, and then plan accordingly. Threatening the client with loss of the position, asking for a new assignment for the client, or arranging for the placement of the client in a skill-training program is inappropriate and premature. CN: Management of care; CL: Synthesize

Question 64

64. A 25-year-old client diagnosed with chronic schizophrenia states, “I stopped my medications a week ago. I was just tired of not being able to drink with my friends. Besides, I feel fine withoutthem.” Which of the following responses by the nurse is most appropriate? 1. “It's important for you to go back on your medicines.” “I hear how difficult it must be to live with the changes caused by your illness.” 3. “You will have to talk to your doctor about stopping your medications.” 4. “Your buddies will understand that you can't drink anymore.”

Answer 64

64. 2. By acknowledging the difficulties of living with the illness, the nurse conveys empathy for the client's feelings and opens up the lines of communication. Although it is important for the client to maintain compliance with medication therapy, telling the client that it is important to start taking them again or to talk with the doctor about stopping the medications ignores the underlying feelings of the client's initial statements. Stating that the client's buddies will understand may or may not be true. Additionally, this statement ignores the underlying feelings. CN: Psychosocial integrity; CL: Synthesize

Question 65

65. A 23-year-old client diagnosed with schizophrenia cheerfully announces, “My mom and I are so excited that I'm pregnant. She's willing to help us take care of the baby too.” Which of the following reasons should cause the nurse to be concerned about this situation? 1. The client did not say that the father of the baby was excited about this. 2. The mother is not likely to provide enough help for what the client needs. 3. Symptom management will be difficult in early pregnancy without medications. 4. The client will have difficulty financially supporting the baby.

Answer 65

65. 3. Because antipsychotic agents cross the placental barrier and can be teratogenic, they are to be avoided during pregnancy, especially during the first trimester. Later in the pregnancy, low doses of medications may be given if necessary. Although the degree of excitement by the father, the mother's ability to provide help, and the client's financial situation may or may not be of concern, the priority in this situation is the safety of the fetus and risks associated with the need for antipsychotic therapy. CN: Reduction of risk potential; CL: Analyze

Question 66

66. Which of the following clients has the least priority for admission to a psychiatric health care facility? A client with a: 1. Potential for self-harm. 2. Potential for harm to others. 3. Grave disability (cannot care for self). 4. Decline in functioning at work.

Answer 66

66. 4. Although all of the options are commonly true, the primary reason for concern is that parents commonly provide financial support and housing for their chronically mentally ill children. The most critical needs after loss of the parents are the lack of financial support and housing, which are hard to replace. CN: Management of care; CL: Analyze

Question 67

67. A client is being discharged before complete stabilization of symptoms. When developing a discharge plan for this client, the nurse should ensure that the client will have: 1. More medical consultations after discharge. 2. Monthly outpatient visits. 3. Many coordinated services. 4. A caring and supportive family.

Answer 67

67. 3. Many coordinated services are needed, including medication management, more frequent outpatient visits, day treatment, or some combination of these, to decrease the risk of relapse, which is common among chronically ill clients. Medical consultations (if needed) would be included in the coordinated services provided. Chronically mentally ill clients who are discharged early, before becoming truly stable, typically require more than monthly outpatient visits because of the high risk of relapse. A caring and supportive family is ideal for all clients but not always available. CN: Management of care; CL: Create

Question 68

68. When developing a community-based service program for clients with chronic mental illnesses, which of the following is the least important? 1. Partial programs. 2. Psychiatric home care. 3. Residential services. 4. Long-term hospitals.

Answer 68

68. 4. For a community-based program, the need for long-term hospitalization is least needed if the other services, such as partial programs, psychiatric home care, and residential services, are available and accessible.CN: Management of care; CL: Apply

Question 69

69. Crisis intervention plays a major role in the management of care for clients with chronic mental illnesses. Although the safety of the client and others is always a priority, these clients typically need crisis intervention in which of the following situations? Select all that apply. 1. Inability to keep outpatient appointments. 2. Signs of relapse and decompensation. 3. Threat of eviction from housing. 4. Unpaid bills and lack of food. 5. Occasionally missing a dose of medication.

Answer 69

69. 2, 3, 4. Although all of the situations require immediate attention, the inability to keep outpatient appointments is less critical than signs of relapse and decompensation, threat of eviction, and unpaid bills and lack of food. Occasionally missing a dose of medication usually will not precipitate a crisis for a client. CN: Psychosocial integrity; CL: Analyze

Question 70

70. The most common reason given by mentally ill clients for noncompliance with medications is their uncomfortable adverse effects. When teaching the families, what need should the nurse identify as the greatest? 1. Alternative ways to manage the adverse effects.2. Home visits to set up a week's supply of medications. 3. Family monitoring of the administration of medication. 4. Outpatient monitoring of medication compliance.

Answer 70

70. 1. Ways to decrease or manage adverse effects without additional medications is crucial. Although home visits, family monitoring, and outpatient monitoring may help, if the adverse effects are not controlled, the client is less likely to take the drug, which would interfere with its effectiveness. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 71

71. The stigma related to having a mental illness, especially a chronic illness, persists despite improvements in the management of illnesses and an increase in public education. Which of the following views most perpetuates the stigma? 1. Mental illness is hereditary. 2. Mental illnesses have biochemical bases. 3. Clients cannot prevent mental illness if they want to do so. 4. Clients can recover from mental illness if they have willpower.

Answer 71

71. 4. Many still believe that recovery from mental illness is a matter of willpower—for example, “pull yourself up by your bootstraps” or “just get over it.” This belief persists despite awareness that mental illness is hereditary and has a biochemical basis. Mental illness can be prevented only if there is early intervention. Clients cannot prevent it just by the desire to do so. CN: Psychosocial integrity; CL: Evaluate

Question 72

The Client with Cognitive Disorders 72. An elderly woman experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's primary health care provider to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the woman: 1. Is experiencing the onset of Alzheimer's disease. 2. Is having trouble adjusting to living alone without her husband. 3. Is having delayed grieving related to her Alzheimer's disease. 4. Is experiencing delirium and a urinary tract infection (UTI).

Answer 72

The Client with Cognitive Disorders 72. 4. Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations. CN: Reduction of risk potential; CL: Analyze

Question 73

73. An elderly client was prescribed Ativan (lorazepam) 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. Which of the following would the nurse suspect as the cause of the mother's behavior, and what action would she suggest? 1. The client is manic and may need a sleeping pill. 2. The client is experiencing a medication interaction and should go to the emergency department. 3. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately. 4. The client is overcome by grief and probably needs an antidepressant

Answer 73

73. 3. Paradoxical responses to benzodiazepines are more common in children and the elderly than other age groups and generally occur at the beginning of treatment. Grief/depression in the elderly is more likely to result in fatigue and withdrawal than hyperactivity and agitation. Treatment with a sleeping medication chemically related to the benzodiazepines is likely to result in an increase rather than decrease in agitation symptoms in elderly clients. A medication interaction is possible, but less likely since most pharmacies screen for drug interactions when filling prescriptions. CN: Pharmacological and parenteral therapies; CL: Analyze

Question 74

74. The son of an elderly client who has cognitive impairments approaches the nurse and says, “I'm so upset. The primary health care provider says I have 4 days to decide on where my dad is going to live.” The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? 1. “Boy, I have a lot to think about before I see the social worker tomorrow.” 2. “I think I can handle most of Dad's needs with the help of some home health care.” 3. “I'm so afraid of making the wrong decision, but I can move him later if I need to.” 4. “I want the social worker to make this decision so Dad won't blame me.”

Answer 74

74. 4. Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed. CN: Management of care; CL: Synthesize

Question 75

75. Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply. 1. Limiting the client's choices. 2. Accepting the client as he is. 3. Allowing the client to do as he wishes. 4. Acting nonchalantly. 5. Explaining to the client what he needs to do step-by-step.

Answer 75

75. 1, 2, 5. Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring. CN: Psychosocial integrity; CL: Synthesize

Question 76

76. The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? 1. Increase the client's confusion and disorientation. 2. Cause the client to become sad. 3. Decrease the client's feelings of isolation and loneliness. 4. Keep the client from participating in therapeutic activities.

Answer 76

76. 3. Reminiscing can help reduce depression in an elderly client and lessens feelings ofisolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing. CN: Psychosocial integrity; CL: Evaluate

Question 77

The Client with Delirium 77. A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, “Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment.” Which of the following responses by the nurse is most appropriate? 1. “Please come away from the door. I'll show you your room.” “It's Tuesday and you are in the hospital. I'm Anne, a nurse.” 3. “The door is locked to keep you from getting lost.” 4. “I want you to come eat your lunch before you go the doctor.”

Answer 77

The Client with Delirium 77. 2. Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation. CN: Psychosocial integrity; CL: Synthesize

Question 78

78. An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and x-rays done that day. The grandson says, “She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest.” The nurse should tell the grandson which of the following? Select all that apply. “I agree she needs to rest, but there is no one specific medicine for your grandmother's condition.” “The doctor will look at the results of those tests in the ED and decide what other tests are needed.” “Delirium commonly results from underlying medical causes that we need to identify and correct.” 4. “Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs.” 5. “I'll ask the doctor to postpone more tests until tomorrow.”

Answer 78

78. 1, 2, 3. The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication prescriptions. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate. CN: Psychosocial integrity; CL: Apply

Question 79

79. The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, “Stop; leave me alone. What are you trying to do to me? What's happening to me?” Which response by the nurse is most appropriate? “The tests of your blood will help us figure out what is happening to you.” 2. “Please hold still so I don't have to stick you a second time.” 3. “After I get your blood, I'll get some medicine to help you calm down.” 4. “I'll tell you everything after I get your blood tests to the laboratory.”

Answer 79

79. 1. Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self-control requiring medication intervention. CN: Psychosocial integrity; CL: Synthesize

Question 80

80. A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection (UTI) and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the client's primary health care provider? 1. A prescription to place the client in restraints. 2. A reevaluation of the client's mental status. 3. The transfer of the client to a medical unit. 4. A transfer of the client to a nursing home.

Answer 80

80. 3. The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point. CN: Management of care; CL: Synthesize

Question 81

``` 81. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure. ```

Answer 81

81. 3. Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual. CN: Reduction of risk potential; CL: Analyze

Question 82

82. In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? 1. Disturbances in cognition and consciousness that fluctuate during the day. 2. The failure to identify objects despite intact sensory functions. 3. Significant impairment in social or occupational functioning over time. 4. Memory impairment to the degree of being called amnesia

Answer 82

82. 1. Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia.CN: Physiological adaptation; CL: Analyze

Question 83

83. Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.

Answer 83

83. 2. The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health. CN: Reduction of risk potential; CL: Apply

Question 84

84. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.

Answer 84

84. 3. In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition. CN: Psychosocial integrity; CL: Create

Question 85

85. Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure that the nurse has the client's attention. 2. Eliminating the client's napping in the daytime as much as possible. 3. Engaging the client in reminiscing with relatives or visitors. 4. Avoiding arguing with a suspicious client about his perceptions of reality.

Answer 85

85. 1. Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time. CN: Psychosocial integrity; CL: Apply

Question 86

86. A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to “catch these baby angels flying around my head.” While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply. 1. Decreasing as much “foreign” stimuli as possible. 2. Avoiding challenging the client's perceptions about “baby angels.” 3. Orienting the client about his medical condition. 4. Gently presenting reality as needed. 5. Calling the client's family to report his onset of dementia.

Answer 86

86. 1, 2, 4. The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia. CN: Psychosocial integrity; CL: Synthesize

Question 87

The Client with Dementia 87. The nurse is assessing an older adult for signs of dementia using the “mini-cog” dementia assessment tool. The nurse gives the client three words to remember: “cat,” “crackers,” and “toys.” After having the client perform a short task, the nurse asks the client to repeat the words. The client says “toys,” “boys,” and “joys.” The nurse should next: 1. Ask the client to repeat the original words one more time. 2. Note on the chart that the client has echolalia. 3. Refer the client to a health care provider for further follow-up. 4. Repeat the test when a family member is present.

Answer 87

The Client with Dementia 87. 3. That the client is not able to recall the three words is a likely indicator of dementia; the nurse should make a referral for further testing. It is recommended not to repeat the test a second time if the client is not able to recall the words. Although the client repeated rhyming words, echolalia refers to repletion of the same word. It is not necessary to have a family member present when conducting the test, but the nurse should communicate the findings to the family and encourage them to seek follow-up assessment. CN: Reduction of risk potentail; CL: Analyze

Question 88

88. A client has been admitted to the emergency room. The client's family tells the nurse that the client has suddenly become lethargic and is “not making sense”. The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has: 1. Dementia. 2. Depression. 3. Delirium. 4. Dehydration.

Answer 88

88. 3. Based on CAM's assessment tool, the client has an acute onset of behaviors, is inattentive, has disorganized thinking, and is lethargic (decreased level of consciousness. This cluster of behaviors constitutes delirium. Dementia has a slow onset, the client's level of consciousness is usually normal, and the client can focus attention. Clients who are depressed are alert and oriented and able to focus attention, although may be easily distracted. Further assessment is needed to determine if the client also is dehydrated. CN: Reduction of risk potential; CL: Analyze

Question 89

89. A nurse on the geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take “on top of his donepezil (Aricept).” The son then asks, “Why does he have to take extra medicines?” The nurse should tell the son: 1. “Maybe the Aricept alone isn't improving his dementia fast enough or well enough.” “Namenda and Aricept are commonly used together to slow the progression of dementia.” 3. “Namenda is more effective than Aricept. Your father will be tapered off the Aricept.” 4. “Aricept has a short half-life and Namenda has a long half-life. They work well together.”

Answer 89

89. 2. The two medicines are commonly given together. Neither medicine will improve dementia,but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours. CN: Pharmacological and parenteral therapies; CL: Apply

Question 90

90. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation

Answer 90

90. 2. Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause extrapyramidal side effects (EPSE), which increase the risk for falls. The client is not agitated, so restraints are not indicated. Ativan may increase fall risk and cause paradoxical excitement. CN: Reduction of risk potential; CL: Synthesize

Question 91

91. A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client? 1. There is only one other client in the dayroom; the rest are in a group session in another room. 2. There are three staff members and one primary health care provider in the nurse's station working on charting. 3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner.4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.

Answer 91

91. 3. The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing. CN: Management of care; CL: Analyze

Question 92

92. Nursing staff are trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should: 1. Move the client to a room near the nurse's station and install a bed alarm. 2. Have the client sleep in a reclining chair across from the nurse's station. 3. Help the client to bed and raise all four bedrails. 4. Ask a family member to stay with the client at night.

Answer 92

92. 1. Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client. CN: Safety and infection control; CL: Synthesize

Question 93

93. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, “She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore.” Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's primary health care provider for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.

Answer 93

93. 2, 3, 4. A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime. CN: Management of care; CL: Synthesize

Question 94

94. A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first? 1. Pick up the fork and feed the client slowly. 2. Say, “It's time for you to start eating your dinner.” 3. Hand the fork to the client and say, “Use this fork to eat your green beans.” 4. Save the client's dinner until her family comes in to feed her.

Answer 94

94. 3. Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client is not successful. CN: Management of care; CL: Synthesize

Question 95

95. A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.

Answer 95

95. 2. Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical. CN: Psychosocial integrity; CL: Analyze

Question 96

96. The client with dementia states to the nurse, “I know you. You're Margaret, the girl who lives down the street from me.” Which of the following responses by the nurse is most therapeutic? “Mrs. Jones, I'm Rachel, a nurse here at the hospital.” 2. “Now Mrs. Jones, you know who I am.” 3. “Mrs. Jones, I told you already, I'm Rachel and I don't live down the street.” 4. “I think you forgot that I'm Rachel, Mrs. Jones.”

Answer 96

96. 1. Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, “I told you already” sounds condescending, as if blaming the client for not remembering. CN: Psychosocial integrity; CL: Synthesize

Question 97

97. While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should: 1. Tell her that she is very rude. 2. Ignore the vulgarity and distract her.3. Tell her to stop swearing immediately. 4. Say nothing and leave the room.

Answer 97

97. 2. Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand. CN: Psychosocial integrity; CL: Synthesize

Question 98

98. The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe dementia may be able to perform which of the following actions? 1. Balance a checkbook accurately. 2. Brush the teeth when handed a toothbrush. 3. Use confabulation when telling a story. 4. Find misplaced car keys.

Answer 98

98. 2. Highly conditioned motor skills, such as brushing teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function. CN: Psychosocial integrity; CL: Analyze

Question 99

99. When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which of the following interventions should the nurse employ as the first step? 1. Using gentle touch to convey empathy. 2. Rephrasing questions the client doesn't understand. 3. Eliminating distracting stimuli such as turning off the television. 4. Asking the client to go for a walk while talking.

Answer 99

99. 3. Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion. CN: Psychosocial integrity; CL: Synthesize

Question 100

100. While educating the daughter of a client with dementia about the illness, the daughter mentions to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? 1. “I tell her reality, such as, ‘That noise is the wind in the trees.’” 2. “I understand the misperceptions are part of the disease.” 3. “I turn off the radio when we're in another room.” “I tell her she is wrong, and then I tell her what's right.”

Answer 100

100. 4. Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues. CN: Psychosocial integrity; CL: Evaluate

Question 101

The Client with Alzheimer's Disease 101. The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, “I'm tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?” The nurse should tell the son: “Your dad lost his short-term memory, but he still has his long-term memory.” 2. “You need to be more accepting of your dad's behavior.” 3. “I want you to understand your dad's level of anxiety.” 4. “Telling your dad that you are tired of hearing about the past will help him stop.”

Answer 101

The Client with Alzheimer's Disease 101. 1. The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will. CN: Psychosocial integrity; CL: Apply

Question 102

102. The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment? 1. The client would have more structure to his day. 2. Staff are excellent in the treatment they offer clients. 3. The client would benefit from increased social interaction. 4. The family would have more time to engage in their daily activities.

Answer 102

102. 3. The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs. CN: Psychosocial integrity; CL: Apply

Question 103

103. When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? 1. Prompting and guiding activities of daily living. 2. Managing a medication schedule. 3. Constant supervision and total care. 4. Supervision of risky activities such as shaving.

Answer 103

103. 1. Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment—that is, when the client still has motor function but lacks judgment about safety issues. CN: Psychosocial integrity; CL: Synthesize

Question 104

104. The family of a client diagnosed with Alzheimer's disease wants to keep the client at home. They say that they have the most difficulty in managing his wandering. The nurse should instruct the family to do which of the following? Select all that apply. 1. Ask the primary health care provider for a sleeping medication. 2. Install motion and sound detectors. 3. Have a relative sit with the client all night. 4. Have the client wear a Medical Alert bracelet. 5. Install door alarms and high door locks.

Answer 104

104. 2, 4, 5. Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden. CN: Psychosocial integrity; CL: Synthesize

Question 105

105. Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? 1. Repeating the directions until the client follows them. 2. Asking the client to do one step of the task at a time. 3. Demonstrating for the client how to do the task. 4. Maintaining routine and structure for the client.

Answer 105

105. 2. Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion. CN: Psychosocial integrity; CL: Synthesize

Question 106

106. The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses is most appropriate? 1. “What makes you think we want to kill you?” 2. “We like you too much to want to kill you.” “You are in the hospital. We are nurses trying to help you.”4. “Oh, don't be so silly. No one wants to kill you here.”

Answer 106

106. 3. The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate. CN: Psychosocial integrity; CL: Synthesize

Question 107

107. When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful? 1. Ignore the behaviors, but try to identify the underlying need for the behaviors. 2. Give feedback on the inappropriateness of the behaviors. 3. Employ anger management strategies. 4. Administer the prescribed risperidone (Risperdal).

Answer 107

107. 1. The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors. CN: Psychosocial integrity; CL: Apply

Question 108

108. The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? 1. “I didn't realize the deterioration would be so incapacitating.” 2. “The Alzheimer's support group has so much good information.” 3. “I get tired of the same old stories, but I know it's important for Dad.” 4. “I woke up this morning expecting that my old Dad would be back.”

Answer 108

108. 4. The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son's part. CN: Psychosocial integrity; CL: Evaluate

Question 109

109. The husband of a client who was diagnosed 6 years ago with Alzheimer's disease approaches the nurse and says, “I'm so excited that my wife is starting to use donepezil (Aricept) for her illness.” The nurse should tell the husband: 1. The medication is effective mostly in the early stages of the illness. 2. The adverse effects of the drug are numerous. 3. The client will attain a functional level of that of 6 years ago. 4. Effectiveness in the terminal phase of the illness is scientifically proven.

Answer 109

109. 1. When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease. CN: Pharmacological and parenteral therapies; CL: Apply

Question 110

110. The primary health care provider prescribes risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.

Answer 110

110. 3. Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.CN: Pharmacological and parenteral therapies; CL: Apply

Question 111

111. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam. The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.

Answer 111

111. 1. Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient. CN: Pharmacology and parental therapies; CL: Apply

Question 112

112. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers.

Answer 112

112. 4. Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe. CN: Psychosocial integrity; CL: Apply

Question 113

Managing Care Quality and Safety 113. An elderly client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, “If my neighbor puts up a fence, I'll blow him away with my shotgun. He has never respected my property line, and I've had it!” Which of the following actions should the nurse take? 1. Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia. 2. Report the comment to the client's daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations. 3. Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control. 4. Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act.

Answer 113

Managing Care Quality and Safety 113. 4. The neighbor could be harmed as well as the daughter if she should try to stop her father from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties. The client's early dementia would likely not prevent him from carrying through his threat. CN: Management of Care; CL: Analyze

Question 114

114. A client reports having blurred vision after 4 days of taking haloperidol (Haldol) 1 mg twice a day, and benztropine (Cogentin) 2 mg twice a day. The nurse contacts the primary health care provider to explain the situation, background, and assessment and make a recommendation. Which information reported to the primary health care provider is the assessment of the situation? 1. “Mr. Roberts is taking 1 mg of Haldol twice a day and Cogentin 2 mg twice a day.” 2. “I think Mr. Roberts might need a lower dose of Cogentin.” 3. “Mr. Roberts reports having blurred vision since this morning.” 4. “The higher dose of Cogentin could be causing Mr. Roberts' blurred vision.”

Answer 114

114. 4. Cogentin has a common side effect of blurred vision. After evaluating the relative doses of Haldol and Cogentin, the assessment would be that the higher dose of Cogentin compared to the dose of Haldol is responsible for the blurred vision. (High doses of Haldol can cause blurred vision at times.) Reporting that Mr. Roberts has blurred vision is the situation. Listing the medications and doses is describing the background. The recommendation would be a lower dose of Cogentin. CN: Management of care; CL: Synthesize

Question 115

115. When developing a teaching plan for the community about managed care models and their effect on clients with chronic mental illnesses, which of the following factors should the nurse include as detrimental to this population? Select all that apply. 1. Restriction in the range and quantity of services. 2. Hospitalization reserved for emergency services. 3. Nonshifting of funding to outpatient services when clients are moved to these services. 4. Loss of the principle of “least restrictive alternative for care.” 5. Lack of sufficient numbers of group homes and supervised apartments.

Answer 115

115. 1, 3. Without a sufficient range and quantity of services, care is inadequate and hospitalization rates increase. Nonshifting of allocated funding to outpatient services has increased the problem with the range and quantity of services. Reserving hospitalization for emergency services was a practice before managed care. The principle of “least restrictive alternative” is still as relevant as it was before managed care. There are not enough group homes available. CN: Management of care; CL: Apply

Question 116

116. When assessing an aggressive client, which of the following behaviors warrants the nurse's prompt reporting and use of safety precautions? 1. Crying when talking about his divorce. 2. Starting a petition to delay bedtime. 3. Declining attendance at a daily group therapy session. 4. Naming another client as his adversary.

Answer 116

116. 4. The client exhibits aggression against his perceived adversary when he names another client as his adversary. The staff will need to watch him carefully for signs of impending violent behavior that may injure others. Crying about a divorce would be appropriate, not pathologic, behavior demonstrating grief over a loss. A petition to delay bedtime would be a positive, direct action aimed at a bothersome situation. Although declining to attend group therapy needs follow-up, there may be any number of unknown reasons for this action. CN: Safety and infection control; CL: Synthesize

Question 117

117. A nurse is planning care for an elderly client with cognitive impairment who is still living at home. Which action should the nurse identify as a priority for safety in planning care for this client? 1. Having two people accompany the client whenever the client is up and about. 2. Ensuring the removal of objects in the client's path that may cause him to trip.3. Putting the client's favorite belongings in a safe place so that he will not lose them. 4. Giving the client his medications in liquid form to make certain that he swallows them.

Answer 117

117. 2. When caring for a client with cognitive impairment, the priority is to ensure that all objects in the client's path are removed to prevent the client from falling. Additional measures, such as having two people accompany the client when he ambulates, placing his favorite things in safekeeping, and giving medications in a liquid form to be sure he swallows them, are less crucial and available. CN: Safety and infection control; CL: Synthesize

Question 118

118. The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which of the following factors should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients? 1. Fears and conflicts about aging. 2. Dislike of physical contact with older people. 3. A desire to be surrounded by beauty and youth. 4. Recent experiences with her mother's elderly friends.

Answer 118

118. 1. The most common reason for the nurse's discomfort with elderly clients is that she has not examined her own fears and conflicts about aging. Until nurses resolve their fears, it is unlikely that they will feel comfortable with elderly clients. A dislike of physical contact with older people, a desire to be surrounded by beauty and youth, and recent experiences with a parent's elderly friends are possible explanations, but not common or likely. CN: Management of care; CL: Analyze