UNIT H Flashcards
A patient has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this patient shouts, “They’re all plotting to destroy me. Isn’t that true?” Select the nurse’s most therapeutic response.
a. “Everyone here is trying to help you. No one wants to harm you.”
b. “Feeling that people want to destroy you must be very frightening.”
c. “That is not true. People here are trying to help you if you will let them.”
d. “Staff members are health care professionals who are qualified to help you.”
ANS: B
Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.
A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly
scans the environment. The patient states, “I saw two doctors talking in the hall. They were plotting to kill me.” The nurse may correctly assess this behavior as
a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination.
ANS: B
Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.
A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two doctors plotting to kill me.” How does this patient perceive the environment?
a. Disorganized
b. Dangerous
c. Supportive d. Bizarre
ANS: B
The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, “I stopped taking those pills. They made me feel like a robot.” What are common side effects the nurse should validate with the patient?
a. Sedation and muscle stiffness
b. Sweating, nausea, and diarrhea
c. Mild fever, sore throat, and skin rash
d. Headache, watery eyes, and runny nose
ANS: A
Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a “robot.” The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.
Which hallucination necessitates the nurse to implement safety measures? The patient says,
a. “I hear angels playing harps.”
b. “The voices say everyone is trying to kill me.”
c. “My dead father tells me I am a good person.”
d. “The voices talk only at night when I’m trying to sleep.”
ANS: B
The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.
A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase
ANS: B
Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.
A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?
a. Clozapine
b. Ziprasidone
c. Olanzapine
d. Aripiprazole
ANS: D
Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.
A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows away. Get it?” Select the nurse’s most therapeutic response.
a. “Nothing you are saying is clear.”
b. “Your thoughts are very disconnected.”
c. “Try to organize your thoughts and then tell me again.”
d. “I am having difficulty understanding what you are saying.”
ANS: D
When a patient’s speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.
A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?
a. Self-esteem
b. Psychosocial
c. Physiological
d. Self-actualization
ANS: C
Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Waxy flexibility may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser concern.
A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient’s activities of daily living are severely compromised. An appropriate outcome would be that the patient will
a. demonstrate increased interest in the environment by the end of week 1.
b. perform self-care activities with coaching by the end of day 3.
c. gradually take the initiative for self-care by the end of week 2.
d. accept tube feeding without objection by day 2.
ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to
perform self-care tasks independently, such as feeding, bathing, dressing, and toileting.
Performing the tasks with coaching by nursing staff denotes improvement over the complete
inability to perform the tasks. The incorrect options are not directly related to self-care
activities, difficult to measure, and unrelated to maintenance of nutrition.
A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?
a. Echolalia
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal
ANS: B
Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.
A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications?
a. Constipation
b. Gynecomastia
c. Visual changes
d. Photosensitivity
ANS: B
FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia (enlargement of the breasts) as well as other changes in sexual function. Men may experience disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing to other aspects of the patient’s physical health but are not likely to bother body image.
A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective?
a. Suggest analogies that might apply to a common daily problem.
b. Assign each participant a problem to solve independently and present to the group.
c. Ask each patient to read aloud a short segment from a book about problem solving.
d. Invite participants to come up with solution to getting incorrect change for a
purchase.
ANS: D
Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things in a literal manner, is evident in many patients diagnosed with schizophrenia. People who think concretely benefit from concrete situations during education. Finding a solution in order to get incorrect change for a purchase is an example of a concrete situation. Analogies require abstract thinking and insight. Independently solving a problem and presenting it to the group may be intimidating. All participants may or may not be literate.
A nurse educates a patient about the antipsychotic medication regime. Afterward, which comment by the patient indicates the teaching was effective?
a. “I will need higher and higher doses of my medication as time goes on.”
b. “I need to store my medication in a cool dark place, such as the refrigerator.”
c. “Taking this medication regularly will reduce the severity of my symptoms.”
d. “If I run out or stop taking my medication, I will experience withdrawal
symptoms. ”
ANS: C
Antipsychotic drugs provide symptom control and allow most patients diagnosed with schizophrenia to live and be treated in the community. Dosing is individually determined. Antipsychotics are not addictive; however, they should be discontinued gradually to minimize a discontinuation syndrome.
A newly admitted patient diagnosed with schizophrenia says, “The voices are bothering me. They yell and tell me I am bad. I have got to get away from them.” Select the nurse’s most helpful reply.
a. “Do you hear the voices often?”
b. “Do you have a plan for getting away from the voices?”
c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”
d. “Forget the voices and ask some other patients to play cards with you.”
ANS: C
Staying with a distraught patient who is hearing voices serves several purposes: ongoing
observation, the opportunity to provide reality orientation, a means of helping dismiss the
voices, the opportunity of forestalling an action that would result in self-injury, and general
support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at
this point. Asking if the patient plans to “get away from the voices” is relevant for
assessment purposes but is less helpful than offering to stay with the patient while
encouraging a focus on their discussion. Suggesting playing cards with other patients shifts
responsibility for intervention from the nurse to the patient and other patients.
A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?
a. Neuroleptic malignant syndrome
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia
ANS: C
Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson’s disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.
A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient’s head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?
a. An acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia
ANS: A
Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.
An acutely violent patient diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the patient’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?
a. Administer diphenhydramine 50 mg IM from the prn medication administration
record.
b. Reassure the patient that the symptoms will subside. Practice relaxation exercises
with the patient.
c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication
administration time.
d. Administer atropine sulfate 2 mg subcut from the prn medication administration
record.
ANS: A
Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.
A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette’s syndrome
d. Anticholinergic effects
ANS: B
Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first-generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette’s syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.
A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse’s most therapeutic response.
a. “Why are you laughing?”
b. “Please share the joke with me.”
c. “I don’t think I said anything funny.”
d. “You’re laughing. Tell me what’s happening.”
ANS: D
The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient’s laughter) and then elicit the patient’s observation. The incorrect options are less useful in eliciting a response: no joke may be involved, “why” questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.
The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?
a. Auditory hallucinations
b. Delusions of grandeur
c. Poor personal hygiene
d. Psychomotor agitation
ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.
What assessment findings mark the prodromal stage of schizophrenia?
a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting
c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility
d. Loose associations, concrete thinking, and echolalia neologisms
ANS: A
Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.
A patient diagnosed with schizophrenia says, “Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people.” Which problem is evident?
a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia
ANS: D
The patient’s unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.
A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The patient is 5’6’’ and currently weighs 204 lbs. The patient has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the patient’s plan of care?
a. Skin care techniques
b. Scheduling a colonoscopy
c. Weight management strategies
d. Teaching to limit caffeine intake
ANS: C
Ziprasidone is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with second-generation antipsychotic medications. The patient is overweight now, so weight management will be especially important. The other interventions may occur in time, but do not have the priority of weight management.
A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident?
a. Neologism
b. Idea of reference
c. Thought broadcasting
d. Associative looseness
ANS: D
Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one’s thoughts.
A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?
a. Haloperidol
b. Olanzapine
c. Chlorpromazine
d. Diphenhydramine
ANS: B
Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine. See relationship to audience response question.
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family’s role in recovery. Which type of therapy should the nurse recommend?
a. Psychoeducational
b. Psychoanalytic
c. Transactional
d. Family
ANS: A
A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.
A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, “My computer is sending out infected radiation beams.” The nurse can correctly assess this information as an indication of
a. the need for psychoeducation.
b. medication nonadherence.
c. chronic deterioration.
d. relapse.
ANS: D
Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication nonadherence may not be implicated. Relapse can occur even when the patient is taking medication
regularly. Psychoeducation is more effective when the patient’s symptoms are stable.
Chronic deterioration is not the best explanation.
A patient diagnosed with schizophrenia begins to talks about “macnabs” hiding in the warehouse at work. The term “macnabs” should be documented as
a. a neologism.
b. concrete thinking.
c. thought insertion.
d. an idea of reference.
ANS: A
A neologism is a newly coined word having special meaning to the patient. “Macnabs” is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one’s mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.
A patient diagnosed with schizophrenia anxiously says, “I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror.” While listening, the nurse should
a. sit close to the patient.
b. place an arm protectively around the patient’s shoulders.
c. place a hand on the patient’s arm and exert light pressure.
d. maintain a normal social interaction distance from the patient.
ANS: D
The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.
A patient diagnosed with schizophrenia anxiously tells the nurse, “The voice is telling me to do things.” Select the nurse’s priority assessment question.
a. “How long has the voice been directing your behavior?”
b. “Does what the voice tell you to do frighten you?”
c. “Do you recognize the voice speaking to you?’
d. “What is the voice telling you to do?”
ANS: D
Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action.
a. Agranulocytosis; institute reverse isolation.
b. Tardive dyskinesia; withhold the next dose of medication.
c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.
d. Neuroleptic malignant syndrome; notify health care provider stat.
ANS: D
Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.
A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?” Which response by the patient indicates concrete thinking?
a. “The table of contents tells what a book is about.”
b. “You can’t judge a book by looking at the cover.”
c. “Things are not always as they first appear.”
d. “Why are you asking me about books?”
ANS: A
Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient’s interpretation of proverbs. Concreteness reduces one’s ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.
The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group? Members will
a. gain insight into unconscious factors that contribute to their illness.
b. explore situations that trigger hostility and anger.
c. learn to manage delusional thinking.
d. demonstrate improved social skills.
ANS: D
Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.
A client says, “Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist.” Select the nurse’s best initial action.
a. Tell the client, “Facebook is a safe website. You don’t need to worry about
Homeland Security.”
b. Tell the client, “You are in a safe place where you will be helped.”
c. Administer a prn dose of an antipsychotic medication. d. Tell the client, “You don’t need to worry about that.”
ANS: B
The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.
Which finding constitutes a negative symptom associated with schizophrenia?
a. Hostility
b. Bizarre behavior
c. Poverty of thought
d. Auditory hallucinations
ANS: C
Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.
A patient insistently states, “I can decipher codes of DNA just by looking at someone.” Which problem is evident?
a. Visual hallucinations
b. Magical thinking
c. Idea of reference
d. Thought insertion
ANS: B
Magical thinking is evident in the patient’s appraisal of his own abilities. There is no evidence of the distracters.
A newly hospitalized patient experiencing psychosis says, “Red chair out town board.” Which term should the nurse use to document this finding?
a. Word salad
b. Neologism
c. Anhedonia
d. Echolalia
ANS: A
Word salad is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.
A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.)
a. “The importance of taking your medication correctly”
b. “How to complete an application for employment”
c. “How to dress when attending community events”
d. “How to give and receive compliments”
e. “Ways to quit smoking”
ANS: A, E
Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients’ physiological well-being. The other topics are also important but are not priority topics.
A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, “Two staff members I saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.)
a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation
ANS: A, B
Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient’s feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.
A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?
a. Increased muscle tension and anxiety
b. Vegetative signs and poor grooming
c. Poor judgment and hyperactivity
d. Cognitive deficits and paranoia
ANS: C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.
A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, “Do you like my scarves? Here they
are my gift to you.” How should the nurse document the patient’s mood? a. Euphoric
b. Irritable
c. Suspicious
d. Confident
ANS: A
The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient’s mood. Suspiciousness is not evident.
A person was directing traffic on a busy street, rapidly shouting, “To work, you jerk, for perks” and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient’s plan of care?
a. Insulting, aggressive behavior
b. Pressured speech and grandiosity
c. Hyperactivity; not eating and sleeping
d. Poor concentration and decision making
ANS: C
Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient’s life.
A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority?
a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Ineffective therapeutic regimen management
ANS: A
Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient’s physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.
A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
a. “Stop that! No one did anything to provoke an attack by you.”
b. “If you do that one more time, you will be secluded immediately.”
c. “Do not hit anyone. If you are unable to control yourself, we will help you.”
d. “You know we will not let you hit anyone. Why do you continue this behavior?”
ANS: C
When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.
This nursing diagnosis applies to a patient experiencing acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will a. ask staff for assistance with feeding within 4 days.
b. drink six servings of a high-calorie, high-protein drink each day.
c. consistently sit with others for at least 30 minutes at meal time within 1 week.
d. consistently wear appropriate attire for age and sex within 1 week while on the
psychiatric unit.
ANS: B
High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient’s extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.
A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? It will
a. minimize the side effects of lithium.
b. bring hyperactivity under rapid control.
c. enhance the antimanic actions of lithium.
d. be used for long-term control of hyperactivity.
ANS: B
Manic symptoms are controlled by lithium only after a therapeutic serum level is attained.
Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce
the hyperactivity initially. Antipsychotic drugs neither enhance lithium’s antimanic activity
nor minimize the side effects. Lithium will be used for long-term control.
A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?
a. phenytoin
b. clonidine
c. risperidone
d. carbamazepine
ANS: D
Some patients diagnosed with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant.
The exact cause of bipolar disorder has not been determined; however, for most patients
a. several factors, including genetics, are implicated.
b. brain structures were altered by stress early in life.
c. excess sensitivity in dopamine receptors may trigger episodes.
d. inadequate norepinephrine reuptake disturbs circadian rhythms.
ANS: A
The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.
The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide?
a. “A high proportion of patients with bipolar disorders are found among creative
writers.”
b. “A higher rate of relatives with bipolar disorder is found among patients with
bipolar disorder.”
c. “Patients with bipolar disorder have higher rates of relatives who respond in an
exaggerated way to daily stress.”
d. “More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.”
ANS: B
Evidence of genetic transmission is supported by lifetime prevalence statistics. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.
A patient diagnosed with bipolar disorder commands other patients, “Get me a book. Take this stuff out of here,” and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select?
a. Distraction: “Let’s go to the dining room for a snack.”
b. Humor: “How much are you paying servants these days?”
c. Limit setting: “You must stop ordering other patients around.”
d. Honest feedback: “Your controlling behavior is annoying others.”
ANS: A
The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.
The nurse receives a laboratory report indicating a patient’s serum level is 1 mEq/L. The patient’s last dose of lithium was 8 hours ago. This result is
a. within therapeutic limits.
b. below therapeutic limits.
c. above therapeutic limits.
d. invalid because of the time lapse since the last dose.
ANS: A
Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.6 to 1.2 mEq/L.
Consider these three anticonvulsant medications: divalproex, carbamazepine, and
gabapentin. Which medication also belongs to this classification? a. clonazepam
b. risperidone
c. lamotrigine
d. aripiprazole
ANS: C
The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.
When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention?
a. Allow the patient to act out feelings.
b. Set limits on patient behavior as necessary.
c. Provide verbal instructions to the patient to remain calm.
d. Restrain the patient to reduce hyperactivity and aggression.
ANS: B
This intervention provides support through the nurse’s presence and provides structure as necessary while the patient’s control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.
At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate?
a. An extra-large window with a view of the street
b. Neutral walls with pale, simple accessories
c. Brightly colored walls and print drapes
d. Deep colors for walls and upholstery
ANS: B
The environment for a manic patient should be as simple and nonstimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.
A patient demonstrating behaviors associated with acute mania has exhausted the staff by
noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially?
a. Confer with the health care provider to consider use of seclusion for this patient.
b. Hold a staff meeting to discuss consistency and limit-setting approaches.
c. Conduct a meeting with all staff and patients to discuss the behavior.
d. Explain to the patient that the behavior is unacceptable.
ANS: B
When staff members are exhausted, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.
A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by
a. quietly asking the patient, “Why don’t you put your clothes on?”
b. firmly telling the patient, “Stop dancing and put on your clothing.”
c. putting a blanket around the patient and walking with the patient to a quiet room.
d. letting the patient stay in the group room and moving the other patients to a
different area.
ANS: C
Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.
A patient waves a newspaper and says, “I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes.” Select the nurse’s appropriate intervention. The nurse
a. suggests the patient have a friend do the shopping and bring purchases to the unit.
b. invites the patient to sit together and look at new fashion magazines.
c. tells the patient computer use is not allowed until self-control improves.
d. asks whether the patient has enough money to pay for the purchases.
ANS: B
Situations such as this offer an opportunity to use the patient’s distractibility to staff’s advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient’s need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.
An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with
a. meals.
b. an antacid.
c. an antiemetic.
d. a large glass of juice.
ANS: A
Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.
A health teaching plan for a patient taking lithium should include instructions to
a. maintain normal salt and fluids in the diet.
b. drink twice the usual daily amount of fluid.
c. double the lithium dose if diarrhea or vomiting occurs.
d. avoid eating aged cheese, processed meats, and red wine.
ANS: A
Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.
Which nursing diagnosis would most likely apply to a patient diagnosed with major depressive disorder as well as one experiencing acute mania?
a. Deficient diversional activity
b. Disturbed sleep pattern
c. Fluid volume excess
d. Defensive coping
ANS: B
Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.
Which dinner menu is best suited for a patient with acute mania?
a. Spaghetti and meatballs, salad, and a banana
b. Beef and vegetable stew, a roll, and chocolate pudding
c. Broiled chicken breast on a roll, an ear of corn, and an apple
d. Chicken casserole, green beans, and flavored gelatin with whipped cream
ANS: C
These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive patient could eat while in motion. The foods in the incorrect options cannot be eaten without utensils.
Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on
a. developing an optimistic outlook.
b. distorted thought self-control.
c. interest in the environment.
d. sleep pattern stabilization.
ANS: B
The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.
Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective?
a. “Converses with few interruptions; clothing matches; participates in activities.”
b. “Irritable, suggestible, distractible; napped for 10 minutes in afternoon.”
c. “Attention span short; writing copious notes; intrudes in conversations.”
d. “Heavy makeup; seductive toward staff; pressured speech.”
ANS: A
The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.
A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?
a. Monitor physiological functioning.
b. Provide a subdued environment.
c. Supervise personal hygiene.
d. Observe for mood changes.
ANS: B
All the options are reasonable interventions for a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.
A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient’s behavior?
a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing.
b. Continue to monitor and document the patient’s speech patterns and motor activity.
c. Ask the health care provider to prescribe an increased dose and frequency of lithium.
d. Consider the need to check the lithium level. The patient may not be swallowing medications.
ANS: D
The patient continues to exhibit manic symptoms. Nonadherence to the medication regime is a common problem for patients diagnosed with bipolar disorder. The lithium level should be approaching a therapeutic range after 7 days but may be low from “cheeking” (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.
A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should a. direct the patient to wear clothes at all times.
b. ask if the patient finds clothes bothersome.
c. tell the patient that others feel embarrassed.
d. arrange for one-on-one supervision.
ANS: D
A patient who repeatedly disrobes despite verbal limit setting needs more structure.
One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.
A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, “I’ll throw the pool balls if anyone comes near me.” To best assure safety, the nurse’s first intervention is to
a. tell the patient, “You need to be secluded.”
b. clear the room of all other patients.
c. help the patient down from the table.
d. assemble a show of force.
ANS: B
The patient’s behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. Threatening the patient or assembling a show of force is likely to exacerbate the tension.
A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient’s family during this phase of treatment?
a. Attending psychoeducation sessions
b. Decreasing physical activity
c. Increasing food and fluids
d. Meeting self-care needs
ANS: A
During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.
A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?
a. Pharyngitis, mydriasis, and dystonia
b. Alopecia, purpura, and drowsiness
c. Diaphoresis, weakness, and nausea
d. Ascites, dyspnea, and edema
ANS: C
Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.
A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, “Do I have to keep taking this lithium even though my mood is stable now?” Select the nurse’s appropriate response.
a. “You will be able to stop the medication in about 1 month.”
b. “Taking the medication every day helps reduce the risk of a relapse.”
c. “Most patients take medication for approximately 6 months after discharge.”
d. “It’s unusual that the health care provider hasn’t already stopped your medication.”
ANS: B
Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication adherence.
An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, “I’ve had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?” The nurse will advise the patient to
a. restrict food and fluids for 24 hours and stay in bed.
b. have someone bring the patient to the clinic immediately.
c. drink a large glass of water with 1 teaspoon of salt added.
d. take one dose of an over-the-counter antidiarrheal medication now.
ANS: B
The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient’s symptoms.
A newly diagnosed patient is prescribed lithium. Which information from the patient’s history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure
ANS: D
The patient with heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.
Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with
a. bipolar I disorder.
b. bipolar II disorder.
c. dysthymic disorder.
d. cyclothymic disorder.
ANS: A
Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.
Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply.)
a. Limit credit card access.
b. Provide a structured environment.
c. Encourage group social interaction.
d. Supervise medication administration.
e. Monitor the patient’s sleep patterns.
ANS: A, B, D, E
A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting
access to cash and credit cards. Continued decline in sleep patterns may indicate the
condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. The family should supervise medication administration to prevent deterioration to a full manic episode and because the patient is at risk to omit medications.
A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.)
a. Imbalanced nutrition: more than body requirements
b. Impaired mood regulation
c. Sleep deprivation
d. Chronic confusion
e. Social isolation
ANS: B, C
People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. The mood evidences euphoria and is labile. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.
A patient tells the nurse, “I’m ashamed of being bipolar. When I’m manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I’m a burden to my family.” These statements support which nursing diagnoses? (Select all that apply.)
a. Powerlessness
b. Defensive coping
c. Chronic low self-esteem
d. Impaired social interaction
e. Risk-prone health behavior
ANS: A, C
Chronic low self-esteem and powerlessness are interwoven in the patient’s statements. No data support the other diagnoses.
The plan of care for a patient in the manic state of bipolar disorder should include which interventions? (Select all that apply.)
a. Touch the patient to provide reassurance.
b. Invite the patient to lead a community meeting.
c. Provide a structured environment for the patient.
d. Ensure that the patient’s nutritional needs are met.
e. Design activities that require the patient’s concentration.
ANS: C, D
People with mania are hyperactive, grandiose, and distractible. It is most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient’s behavior is less grandiose. Activities that require concentration will produce frustration.
A patient became severely depressed when the last of the family’s six children moved out of the home 4 months ago. The patient repeatedly says, “No one cares about me. I’m not worth anything.” Which response by the nurse would be the most helpful?
a. “Things will look brighter soon. Everyone feels down once in a while.”
b. “Our staff members care about you and want to try to help you get better.”
c. “It is difficult for others to care about you when you repeatedly say the same
negative things.”
d. “I’ll sit with you for 10 minutes now and 10 minutes after lunch to help you feel
that I care about you.”
ANS: D
Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is “offering self.” Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.
A patient became depressed after the last of the family’s six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will
a. verbalize realistic positive characteristics about self by (date).
b. agree to take an antidepressant medication regularly by (date).
c. initiate social interaction with another person daily by (date).
d. identify two personal behaviors that alienate others by (date).
ANS: A
Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.
A patient diagnosed with major depressive disorder says, “No one cares about me anymore. I’m not worth anything.” Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient?
a. “You look nice this morning.”
b. “You’re wearing a new shirt.”
c. “I like the shirt you are wearing.”
d. “You must be feeling better today.”
ANS: B
Patients with depression usually see the negative side of things. The meaning of compliments may be altered to “I didn’t look nice yesterday” or “They didn’t like my other shirt.” Neutral comments such as making an observation avoid negative interpretations. Saying, “You look nice” or “I like your shirt” gives approval (nontherapeutic techniques). Saying “You must be feeling better today” is an assumption, which is nontherapeutic.
An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?
a. Social skills training
b. Relaxation training classes
c. Desensitization techniques
d. Use of complementary therapy
ANS: A
Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient’s support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skills training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.
Priority interventions for a patient diagnosed with major depressive disorder and feelings of worthlessness should include
a. distracting the patient from self-absorption.
b. careful unobtrusive observation around the clock.
c. allowing the patient to spend long periods alone in meditation.
d. opportunities to assume a leadership role in the therapeutic milieu.
ANS: B
Approximately two-thirds of people with depression contemplate suicide. Patients with depressive disorder who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.
When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using
a. psychoanalytic therapy.
b. desensitization therapy.
c. cognitive-behavioral therapy.
d. alternative and complementary therapies.
ANS: C
Cognitive-behavioral therapy attempts to alter the patient’s dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.
A patient says to the nurse, “My life doesn’t have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” The nurse documents this report as an example of
a. dysthymia.
b. anhedonia.
c. euphoria.
d. anergia.
ANS: B
Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means “without energy.”
A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the patient says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse will
a. limit the patient’s activities to those that can be performed in a sitting position.
b. withhold the drug, force oral fluids, and notify the health care provider.
c. teach the patient strategies to manage postural hypotension.
d. update the patient’s mental status examination.
ANS: C
Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient’s treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?
a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention
ANS: D
All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.
A patient diagnosed with major depressive disorder tells the nurse, “Bad things that happen are always my fault.” Which response by the nurse will best assist the patient to reframe this overgeneralization?
a. “I really doubt that one person can be blamed for all the bad things that happen.”
b. “Let’s look at one bad thing that happened to see if another explanation exists.”
c. “You are being extremely hard on yourself. Try to have a positive focus.”
d. “Are you saying that you don’t have any good things happen?”
ANS: B
By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.
A nurse worked with a patient diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of
a. guilt and despair.
b. over-involvement.
c. interest and pleasure.
d. ineffectiveness and frustration.
ANS: D
Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient’s progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient’s resistance. Guilt and despair might be seen when the nurse experiences the patient’s feelings because of empathy. Interest is possible, but not the most likely result.
A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about
a. restricting sodium intake to 1 gram daily.
b. minimizing exposure to bright sunlight.
c. reporting increased suicidal thoughts.
d. maintaining a tyramine-free diet.
ANS: C Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.
A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve?
a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
b. Mashed potatoes, ground beef patty, corn, green beans, apple pie
c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
ANS: B
The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.
What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment?
a. Nutrition and hydration
b. Supporting physiological stability
c. Reducing disorientation and confusion
d. Assisting the patient to identify and test negative thoughts
ANS: B
During the immediate posttreatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate posttreatment period because the patient may be confused.
A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. can identify foods with high selenium content that should be avoided.
d. confers with a pharmacist when selecting over-the-counter medications.
ANS: D
Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.
Major depressive disorder resulted after a patient’s employment was terminated. The patient now says to the nurse, “I’m not worth the time you spend with me. I am the most useless person in the world.” Which nursing diagnosis applies?
a. Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity
ANS: C
The patient’s statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.
A patient diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective?
a. Make observations.
b. Ask the patient direct questions.
c. Phrase questions to require yes or no answers.
d. Frequently reassure the patient to reduce guilt feelings.
ANS: A
Making observations about neutral topics draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse’s presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.
A patient being treated for depression has taken sertraline daily for a year. The patient calls
the clinic nurse and says, “I stopped taking my antidepressant 2 days ago. Now I am having
nausea, nervous feelings, and I can’t sleep.” The nurse will advise the patient to:
a. “Go to the nearest emergency department immediately.”
b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.”
c. “Take a dose of your antidepressant now and come to the clinic to see the health
care provider.”
d. “Resume taking your antidepressants for 2 more weeks and then discontinue them
again.”
ANS: C
The patient has symptoms associated with abrupt withdrawal of the antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.
Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan was effective?
a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing
grandchild.
b. Slept 10 hours uninterrupted. Attended craft group; stated “project was a failure, just like me.”
c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.
d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, “I feel tired all the time.”
ANS: A
Sleeping 6 hours, participating with a group, and anticipating an event are all positive findings that suggest effectiveness of the plan of care. All the other options show at least one negative finding.
A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient’s symptoms be most acute?
a. January
b. April
c. June
d. September
ANS: A
The days are short in January, so the patient would have the least exposure to sunlight. SAD is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.
A patient diagnosed with major depressive disorder repeatedly tells staff, “I have cancer. It’s my punishment for being a bad person.” Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
a. Powerlessness
b. Risk for suicide
c. Stress overload
d. Spiritual distress
ANS: B
A patient diagnosed with major depressive disorder who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.
A patient diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient?
a. Tomato juice
b. Orange juice
c. Hot tea
d. Milk
ANS: D
Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.
During a psychiatric assessment, the nurse observes a patient’s facial expression is without emotion. The patient says, “Life feels so hopeless to me. I’ve been feeling sad for several months.” How will the nurse document the patient’s affect and mood?
a. Affect depressed; mood flat
b. Affect flat; mood depressed
c. Affect labile; mood euphoric
d. Affect and mood are incongruent.
ANS: B
Mood refers to a person’s self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person’s expression, the affect is flat.
A disheveled patient in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. The nurse will
a. bring up the issue at the community meeting.
b. calmly tell the patient, “You must bathe daily.”
c. make observations about the patient’s poor personal hygiene.
d. firmly and neutrally assist the patient with showering.
ANS: D
When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. The patient needs assistance, not simply making an observation. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.
A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient now says, “This medicine isn’t working.” The nurse’s best intervention would be to
a. discuss with the health care provider the need to increase the dose.
b. reassure the patient that the medication will be effective soon.
c. explain the time lag before antidepressants relieve symptoms.
d. critically assess the patient for symptoms of improvement.
ANS: C
Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.
A patient is experiencing psychomotor agitation associated with major depressive disorder. Which observation would the nurse associate with this symptom? The patient
a. paces aimlessly around the room.
b. asks the nurse to repeat instructions.
c. complains of prickly skin sensations.
d. demonstrates slowed verbal responses.
ANS: A
Psychomotor agitation may be evidenced by constant pacing and wringing of hands. Slowed movements and responses are aspects of psychomotor retardation. Complaints of the unusual skin sensations may represent a delusion or hallucination. Asking the nurse to repeat instructions indicates difficulty with concentration.
A patient diagnosed with major depressive disorder received six ECT sessions and aggressive
doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
a. Antidepressant medications alter catecholamine levels, which impairs
decision-making abilities.
b. Antidepressant medications may cause confusion related to limitation of tyramine
in the diet.
c. Temporary memory impairments and confusion may occur with ECT.
d. The patient needs time to readjust to a pressured work schedule.
ANS: C
Recent memory impairment and/or confusion may be present during and for a short time after ECT. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.
A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of
a. hypotensive shock.
b. hypertensive crisis.
c. cardiac dysrhythmia.
d. cardiogenic shock.
ANS: B
Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.
Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depressive disorder. Which comment by the patient indicates teaching about the procedure was effective?
a. “They will put me to sleep during the procedure so I won’t know what is
happening. ”
b. “I might be a little dizzy or have a mild headache after each procedure.”
c. “I will be unable to care for my children for about 2 months.”
d. “I will avoid eating foods that contain tyramine.”
ANS: B
TCM treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.
The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.)
a. Channeling excessive energy
b. Reducing guilty ruminations
c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardation
ANS: C, D, E
Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.
A nurse caring for a patient diagnosed with major depressive disorder reads in the patient’s medical record, “This patient shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.)
a. Imbalanced nutrition: less than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia
ANS: A, C, D, F
Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self.
A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.)
a. Offer laxatives if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
d. Eliminate all daily caffeine intake.
e. Restrict intake of processed foods.
ANS: A, B, C
The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.
A patient being treated with paroxetine 50 mg po daily reports to the clinic nurse, “I took a few extra tablets earlier today and now I feel bad.” Which assessments are most critical? (Select all that apply.)
a. Vital signs
b. Urinary frequency
c. Psychomotor retardation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness
ANS: A, D, E
The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected.
A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first?
a. Verify the patient’s learning style.
b. Lower the patient’s current anxiety.
c. Create outcomes and a teaching plan.
d. Assess how the patient uses defense mechanisms.
ANS: B
A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient’s anxiety level. Use of defense mechanisms does not apply.
A woman is 5’7”, 160 lbs. and wears a size 8 shoe. She says, “My feet are huge. I’ve asked three orthopedists to surgically reduce my feet.” This person tries to buy shoes to make her
feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
a. Social anxiety disorder
b. Body dysmorphic disorder
c. Separation anxiety disorder
d. Obsessive-compulsive disorder due to a medical condition
ANS: B
Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient’s feet are proportional to the rest of the body. In obsessive-compulsive or related disorder due to a medical condition, the individual’s symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.
A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be:
a. “What would you like me to do to help you?”
b. “Why do you suppose you are feeling anxious?”
c. “I’m not sure I understand. Give me an example.”
d. “You must get your feelings under control before we can continue.”
ANS: C
Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic; the patient likely does not have an answer. The patient may be unable to determine what he or she would like the nurse to do in order to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. The initial nursing intervention of highest priority is to
a. provide for the patient’s safety.
b. encourage clarification of feelings.
c. respect the patient’s personal space.
d. offer an outlet for the patient’s energy.
ANS: A
Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient’s energy can occur when the current panic level subsides. Respecting the patient’s personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.
A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?
a. Fear
b. Risk for injury
c. Self-care deficit
d. Disturbed thought processes
ANS: B
A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.
A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of
a. flooding.
b. desensitization.
c. relaxation technique.
d. cognitive restructuring.
ANS: D
Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.
A patient undergoing diagnostic tests says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily
fatigued. Which defense mechanism is the patient using? a. Displacement
b. Regression
c. Projection
d. Denial
ANS: D
Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one’s own unacceptable thoughts or feelings to another.
A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
ANS: B
Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.
A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?
a. Reassure the patient that all nurses are skilled in providing postoperative care.
b. Present the information again in a calm manner using simple language.
c. Tell the patient that staff is prepared to promote recovery.
d. Encourage the patient to express feelings to family.
ANS: B
Giving information in a calm, simple manner will help the patient grasp the important facts. Introducing extraneous topics as described in the distracters will further scatter the patient’s attention.
A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about
feelings and concerns. What is the rationale for this intervention?
a. Offering hope allays and defuses the patient’s anxiety.
b. Concerns stated aloud become less overwhelming and help problem solving begin.
c. Anxiety is reduced by focusing on and validating what is occurring in the
environment.
d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
ANS: B
All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.
A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?
a. “Have you been a victim of a crime or seen someone badly injured or killed?”
b. “Do you feel especially uncomfortable in social situations involving people?”
c. “Do you repeatedly do certain things over and over again?”
d. “Do you find it difficult to control your worrying?”
ANS: D
Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.
A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient?
a. An interview room furnished with a desk and two chairs
b. A small, empty storage room with no windows or furniture
c. A room with an examining table, instrument cabinets, desk, and chair
d. The nurse’s office, furnished with chairs, files, magazines, and bookcases
ANS: A
Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse’s office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe.
A person has minor physical injuries after an auto accident. The person is unable to focus and says, “I feel like something awful is going to happen.” This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person’s level of anxiety?
a. Mild
b. Moderate c. Severe
d. Panic
ANS: C
The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.
Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, “The nurse manager had a headache the day I was interviewed.” Which defense mechanism is evident?
a. Introjection
b. Conversion
c. Projection
d. Splitting
ANS: C
Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.
A patient tells a nurse, “My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she’s had.” This patient is demonstrating
a. denial.
b. projection.
c. rationalization.
d. compensation.
ANS: C
Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.
A patient experiences a sudden episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to give as a prn anxiolytic?
a. buspirone
b. lorazepam
c. amitriptyline
d. desipramine
ANS: B
Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.
Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse’s response?
a. Altruism
b. Suppression
c. Intellectualization
d. Reaction formation
ANS: A
Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse’s reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.
A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of
a. repression.
b. devaluation.
c. identification.
d. compensation.
ANS: D
Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.
A person speaking about a rival for a significant other’s affection says in an emotional, syrupy voice, “What a lovely person. That’s someone I simply adore.” The individual is demonstrating
a. reaction formation.
b. repression.
c. projection.
d. denial.
ANS: A
Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.
An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?
a. Rationalization
b. Compensation
c. Introjection d. Regression
ANS: A
Rationalization involves unconsciously making excuses for one’s behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.
A student says, “Before taking a test, I feel very alert and a little restless.” The nurse can correctly assess the student’s experience as
a. culturally influenced.
b. displacement.
c. trait anxiety.
d. mild anxiety.
ANS: D
Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.
A student says, “Before taking a test, I feel very alert and a little restless.” Which nursing intervention is most appropriate to assist the student?
a. Explain that the symptoms result from mild anxiety and discuss the helpful
aspects.
b. Advise the student to discuss this experience with a health care provider.
c. Encourage the student to begin antioxidant vitamin supplements.
d. Listen attentively, using silence in a therapeutic way.
ANS: A
Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.
A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism?
a. “I don’t know why I do mean things.”
b. “I have always had poor impulse control.”
c. “That person should not have provoked me.”
d. “I’m really a coward who is afraid of being hurt.”
ANS: C
Rationalization consists of justifying one’s unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. The distracters indicate some measure of acceptance of responsibility for the behavior.
A patient experiencing panic suddenly began running and shouting, “I’m going to explode!” Select the nurse’s best action.
a. Ask, “I’m not sure what you mean. Give me an example.”
b. Capture the patient in a basket-hold to increase feelings of control.
c. Tell the patient, “Stop running and take a deep breath. I will help you.”
d. Assemble several staff members and say, “We will take you to seclusion to help
you regain control.”
ANS: C
Safety needs of the patient and other patients are a priority. Comments to the patient should be simple, neutral, and give direction to help the patient regain control. Running after the patient will increase the patient’s anxiety. More than one staff member may be needed to provide physical limits, but using seclusion or physically restraining the patient prematurely is unjustified. Asking the patient to give an example would be futile; a patient in panic processes information poorly.
A person who has been unable to leave home for more than a week because of severe anxiety says, “I know it does not make sense, but I just can’t bring myself to leave my apartment alone.” Which nursing intervention is appropriate?
a. Help the person use online video calls to provide interaction with others.
b. Advise the person to accept the situation and use a companion.
c. Ask the person to explain why the fear is so disabling.
d. Teach the person to use positive self-talk techniques.
ANS: D
Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as “I can’t leave my apartment” with positive thoughts such as “I can control my anxiety.” This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.
A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?
a. “I check where my car keys are eight times.”
b. “My legs often feel weak and spastic.”
c. “I’m embarrassed to go out in public.”
d. “I keep reliving a car accident.”
ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating “My legs feel weak most of the time” is more in keeping with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.
When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to
a. report drowsiness.
b. eat a tyramine-free diet.
c. avoid alcoholic beverages.
d. adjust dose and frequency based on anxiety level.
ANS: C
Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.
The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia?
a. “I’m sure I will get over not wanting to leave home soon. It takes time.”
b. “Being afraid to go out seems ridiculous, but I can’t go out the door.”
c. “My family says they like it now that I stay home most of the time.”
d. “When I have a good incentive to go out, I can do it.”
ANS: B
Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, patients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.
A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis?
a. feelings of responsibility for the health of family members
b. approval-seeking behavior from friends and family
c. persistent thoughts about bacteria, germs, and dirt
d. needs to avoid interactions with others
ANS: C
Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for anxiety relief. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.
A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping?
a. Allow the patient to set a hand-washing schedule.
b. Encourage the patient to participate in social activities.
c. Encourage the patient to discuss hand-washing routines.
d. Focus on the patient’s symptoms rather than on the patient.
ANS: B
Because obsessive-compulsive patients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping. Daily activities prevent constant focus on anxiety and symptoms. The other interventions focus on the compulsive symptom.
For a patient experiencing panic, which nursing intervention should be implemented first?
a. Teach relaxation techniques.
b. Administer an anxiolytic medication.
c. Prepare to implement physical controls.
d. Provide calm, brief, directive communication.
ANS: D
Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.
A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? (Select all that apply.)
a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.
ANS: A, B, E
The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns.
A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.)
a. Caution in use of machinery
b. Foods allowed on a tyramine-free diet
c. The importance of caffeine restriction
d. Avoidance of alcohol and other sedatives
e. Take the medication on an empty stomach
ANS: A, C, D
Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.
Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)
a. “Are there certain social situations that cause you to feel especially
uncomfortable?”
b. “Are there others in your family who must do things in a certain way to feel
comfortable?”
c. “Have you been a victim of a crime or seen someone badly injured or killed?”
d. “Is it difficult to keep certain thoughts out of your awareness?”
e. “Do you do certain things over and over again?”
ANS: B, D, E
The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia.
The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)
a. Ineffective home maintenance
b. Situational low self-esteem
c. Chronic low self-esteem
d. Disturbed body image
e. Risk for injury
ANS: A, C, E
Shame regarding the appearance of one’s home is associated with hoarding. The behavior is usually associated with chronic low self-esteem. Hoarding results in problems of home maintenance, which may precipitate injury. The self-concept may be affected, but not body image.
A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care?
a. Trigger flashbacks intentionally in order to help the patient learn to cope with
them.
b. Explain that the physical symptoms are related to the psychological state.
c. Encourage repression of memories associated with the traumatic event.
d. Support “numbing” as a temporary way to manage intolerable feelings.
ANS: B
Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body’s responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.
Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who
a. visit their teenager’s grave daily.
b. return immediately to employment.
c. discuss the accident within the family only.
d. create a scholarship fund at their child’s high school.
ANS: D
Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.
After the sudden death of his wife, a man says, “I can’t live without her … she was my whole life.” Select the nurse’s most therapeutic reply.
a. “Each day will get a little better.”
b. “Her death is a terrible loss for you.”
c. “It’s important to recognize that she is no longer suffering.”
d. “Your friends will help you cope with this change in your life.”
ANS: B
Adjustment disorders may be associated with grief. A statement that validates a bereaved person’s loss is more helpful than false reassurances and clichés. It signifies understanding.
A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, “If you had given him your undivided attention, he would still be alive.” How should the nurse analyze this behavior?
a. The comment suggests potential allegations of malpractice.
b. In some cultures, grief is expressed solely through anger.
c. Anger is an expected emotion in an adjustment disorder.
d. The patient had ambivalent feelings about her husband.
ANS: C
Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.
A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, “He would still be alive if you had given him your undivided attention.” Select the nurse’s best intervention.
a. Say to the wife, “I understand you are feeling upset. I will stay with you until your
family comes.”
b. Say to the wife, “Your husband’s heart was so severely damaged that it could no
longer pump.”
c. Say to the wife, “I will call the health care provider to discuss this matter with
you.”
d. Hold the wife’s hand in silence until the family arrives.
ANS: A
The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.
A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child’s parents have adapted to their loss? The parents
a. visit their child’s grave daily.
b. maintain their child’s room as the child left it 2 years ago.
c. keep a place set for the dead child at the family dinner table.
d. throw flowers on the lake at each anniversary date of the accident.
ANS: D
Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.
A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse’s most therapeutic response.
a. “Are you taking your medications the way they are prescribed?”
b. “This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?”
c. “I’m worried about how much you are crying. Your grief over your husband’s death has gone on too long.”
d. “The unexpected death of your husband is very painful. I’m glad you are able to
talk about your feelings.”
ANS: D
The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse’s priority intervention is to form a therapeutic alliance and support the patient’s expression of feelings. Crying at 2 weeks after his death is expected and normal.
Which scenario demonstrates a dissociative fugue?
a. After being caught in an extramarital affair, a man disappeared but then reappeared
months later with no memory of what occurred while he was missing.
b. A man is extremely anxious about his problems and sometimes experiences dazed
periods of several minutes passing without conscious awareness of them.
c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to
new restaurants, and complains of “blackouts” despite not drinking.
d. A woman reports that when she feels tired or stressed, it seems like her body is not
real and is somehow growing smaller.
ANS: A
The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from one’s body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are “lost” to the patient (blackouts).
The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is
a. risk for self-harm.
b. cognitive function.
c. memory impairment.
d. condition of self-esteem.
ANS: A
Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.
A patient states, “I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school.” This scenario is most suggestive of which health problem?
a. Acute stress disorder
b. Dissociative amnesia
c. Depersonalization disorder
d. Disinhibited social engagement disorder
ANS: C
Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD (Acute Stress Disorder) experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.
The unlicensed assistive personnel (UAP) says to the nurse, “That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?” Select the nurse’s best reply.
a. “Spend as much time with her as you can and ask questions about her life.”
b. “Use short, simple sentences and keep the environment calm and protective.”
c. “Provide more information about her past to reduce the mysteries that are causing
anxiety. ”
d. “Structure her time with activities to keep her busy, stimulated, and regaining
concentration. ”
ANS: B
Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patient’s time should not be loaded with demanding or stimulating activities.
A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel as though I’m going to float away.” Which intervention would be most appropriate at this point?
a. Notify the health care provider of this change in the patient’s behavior.
b. Engage the patient in a physical activity such as exercise.
c. Isolate the patient until the sensation has diminished.
d. Administer a prn dose of antianxiety medication.
ANS: B
Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.
A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience?
a. Limbic system
b. Peripheral nervous system
c. Sympathetic nervous system
d. Parasympathetic nervous system
ANS: C
The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.
The gas pedal on a person’s car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect?
a. Weight gain
b. Flashbacks
c. Headache
d. Diuresis
ANS: B
The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or “mind flight” may occur for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the distracters may or may not occur.
A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse’s highest priority is to screen this soldier for
a. bipolar disorder.
b. schizophrenia.
c. depression.
d. dementia.
ANS: C
Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.
Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse’s immediate attention?
a. “It’s good to be home. I missed my home, family, and friends.”
b. “I saw my best friend get killed by a roadside bomb. I don’t understand why it wasn’t me.”
c. “Sometimes I think I hear bombs exploding, but it’s just the noise of traffic in my hometown.”
d. “I want to continue my education, but I’m not sure how I will fit in with other college students.”
ANS: B
The correct response indicates the soldier is thinking about death and feeling survivor’s guilt. These emotions may accompany suicidal ideation, which warrants the nurse’s follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.
A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, “If there’s a loud noise at night, I get under my bed because I think we’re getting bombed.” What type of experience has the soldier described?
a. Illusion
b. Flashback
c. Nightmare
d. Auditory hallucination
ANS: B
Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.
A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier?
a. Halloween festival with neighborhood children
b. Singing carols around a Christmas tree
c. A family outing to the seashore
d. Fireworks display on July 4th
ANS: D
The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.
Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management?
a. “Our children will be stronger if they make their own decisions.”
b. “We spend daily family time talking about experiences and feelings.”
c. “We use three different babysitters. All of them have college degrees.”
d. “Our parenting strategies are different from those our own parents used.”
ANS: B
The correct response demonstrates consistent nurturing, which is a vital component of building resilience in children. The incorrect responses are not necessarily unhealthy parenting behaviors, but they do not clearly demonstrate parental nurturing.
A soldier in a combat zone tells the nurse, “I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind.” Which phenomenon associated with PTSD is the soldier describing?
a. Reexperiencing
b. Hyperarousal c. Avoidance
d. Psychosis
ANS: A
Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.
A soldier who served in a combat zone returned to the United States. The soldier’s spouse complains to the nurse, “We had planned to start a family, but now he won’t talk about it. He won’t even look at children.” The spouse is describing which symptom associated with PTSD?
a. Reexperiencing
b. Hyperarousal
c. Avoidance
d. Psychosis
ANS: C
Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual’s avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.
A soldier returned home last year after deployment to a war zone. The soldier’s spouse complains, “We were going to start a family, but now he won’t talk about it. He will not look at children. I wonder if we’re going to make it as a couple.” Select the nurse’s best response.
a. “Posttraumatic stress disorder (PTSD) often changes a person’s sexual
functioning.”
b. “I encourage you to continue to participate in social activities where children are
present.”
c. “Have you talked with your spouse about these reactions? Sometimes we just need
to confront behavior.”
d. “Posttraumatic stress disorder often strains relationships. Here are some
community resources for help and support.”
ANS: D
PTSD precipitates changes that can lead to divorce. It is important to provide support to both the veteran and spouse. Confrontation will not be effective. While it is important to provide information, on-going support will be more effective.
Which assessment finding best supports dissociative fugue? The patient states
a. “I cannot recall why I’m living in this town.”
b. “I feel as if I’m living in a fuzzy dream state.”
c. “I feel like different parts of my body are at war.”
d. “I feel very anxious and worried about my problems.”
ANS: A
The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.
After major reconstructive surgery, a patient’s wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which physiological response would be expected for this patient?
a. Vital signs return to normal.
b. Release of endogenous opioids would cease.
c. Pulse and blood pressure readings are elevated.
d. Psychomotor abilities of the right brain become limited.
ANS: A
The scenario presents chronic and potentially debilitating stress. The helpless and out of control feelings produce pathophysiological changes. Unmyelinated ventral vagus responses initially result in rapid heart rate and respiration. After many hours, days, or months the body cannot sustain this state, so the dorsal vagal response dampens the sympathetic nervous system. This parasympathetic response results in the heart rate and respiration slowing down and a decrease in blood pressure. Individuals with dissociative disorders have altered communication between higher and lower brain structures due to the massive release of endogenous opioids at the time of severe threat.
Relaxation techniques help patients who have experienced major traumas because they
a. engage the parasympathetic nervous system.
b. increase sympathetic stimulation.
c. increase the metabolic rate.
d. release hormones.
ANS: A
In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response
with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.
Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder. Disturbed personal identity related to
a. obsessive fears of harming self or others.
b. poor impulse control and lack of self-confidence.
c. depressed mood secondary to nightmares and intrusive thoughts.
d. cognitive distortions associated with unresolved childhood abuse issues.
ANS: D
Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.
A young adult says, “I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don’t remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them.” Which disorders should the nurse suspect based on this history? (Select all that apply.)
a. Acute stress disorder
b. Depersonalization disorder
c. Generalized anxiety disorder
d. PTSD
e. Reactive attachment disorder
f. Disinhibited social engagement disorder
ANS: A, B, D
Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient’s presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.
A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster
parents? The nurse should recommend (Select all that apply)
a. conveying empathy and acknowledging the child’s distress.
b. explaining and reinforcing reality to avoid distortions.
c. using a calm manner and low, comforting voice.
d. avoiding repetition in what is said to the child.
e. staying with the child until the anxiety decreases.
f. minimizing opportunities for exercise and play.
ANS: A, B, C, E
The child’s symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child’s distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.
The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply)
a. avoids people and places that arouse painful memories.
b. experiences flashbacks or re-experiences the trauma.
c. experiences symptoms suggestive of a heart attack.
d. feels compelled to repeat selected ritualistic behaviors.
e. demonstrates hypervigilance or distrusts others.
f. feels detached, estranged, or empty inside.
ANS: A, B, C, E, F
These assessment findings are consistent with the symptoms of PTSD. Ritualistic behaviors are expected in obsessive-compulsive disorder.
Which experiences are most likely to precipitate PTSD? (Select all that apply).
a. A young adult bungee jumped from a bridge with a best friend.
b. An 8-year-old child watched an R-rated movie with both parents.
c. An adolescent was kidnapped and held for 2 years in the home of a sexual
predator.
d. A passenger was in a bus that overturned on a sharp curve and tumbled down an
embankment.
e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the
supporting cable breaks.
ANS: C, D, E
PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual’s extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.
The nurse is caring for a patient who is taking chlorpromazine HCl (Thorazine) 75 mg BID to treat schizophrenia. A family member tells the nurse that the patient’s agitation, hallucinations, and delusional symptoms have improved with use of the drug, but the patient continues to withdraw from social interaction and won’t bathe unless reminded to do so. The nurse will tell the family member that:
a. all symptoms will eventually resolve over time with this medication.
b. the patient may need an increased dose of their current antipsychotic medication.
c. these results may indicate that the patient does not have schizophrenia.
d. they should consider discussing changing the chlorpromazine to an atypical
antipsychotic.
ANS: D Chlorpromazine is a typical antipsychotic medication; drugs in this class manage positive symptoms rather than the negative symptoms of withdrawal and poor self-care. It is not likely that the negative symptoms will improve over time with this medication. Atypical antipsychotics can help with both positive and negative symptoms, so it would be worthwhile discussing a change in medication to see if the patient’s negative symptoms could be improved. Increasing the dose will not improve control of negative symptoms. This patient exhibits signs of schizophrenia.
The nurse is assessing a young adult patient with schizophrenia who recently began taking fluphenazine (Prolixin). The patient is exhibiting spasms of facial muscles along with grimacing, and the nurse notes upward eye movements. The nurse suspects which side effect?
a. Acute dystonia
b. Akathisia
c. Pseudoparkinsonism
d. Tardive dyskinesia
ANS: A
Acute dystonia can occur within days of taking typical antipsychotics, and facial muscle spasms, grimacing, and upward eye movements are characteristic of this side effect. Akathisia is characterized by restlessness, pacing, and difficulty standing still. Pseudoparkinsonism is characterized by stooped posture, pill-rolling, shuffling gait, and tremors at rest. Tardive dyskinesia manifests as protrusion and rolling of the tongue, smacking of the lips, and involuntary movement of the body and extremities.
The nurse is preparing to administer loxapine (Loxitane) 50 mg to a patient who has schizophrenia. The patient has been taking this medication twice daily for 15 months. The nurse notes smacking lip movements and involuntary movements of all extremities. Which initial action by the nurse would be most appropriate?
a. Administer the medication as ordered to treat these symptoms of psychosis.
b. Hold the dose and notify the provider of these medication adverse effects.
c. Request an order for an anticholinergic medication such as benztropine (Cogentin).
d. Suggest that the provider increase the dose to 125 mg twice daily.
ANS: B
Tardive dyskinesia manifests as protrusion and rolling of the tongue, smacking of the lips, and involuntary movement of the body and extremities and is a serious adverse effect of antipsychotic medications. The provider should be notified, so the drug can be stopped and a different medication ordered. These are not symptoms of psychosis. Anticholinergic medications are used to combat acute dystonia. Increasing the dose of this medication would potentially exacerbate these adverse effects.
A patient who takes loxapine (Loxitane) to treat schizophrenia is noted to be restless and fidgety and is pacing around the room. The nurse caring for this patient will perform which action?
a. Contact the provider to discuss changing to benztropine (Cogentin).
b. Notify the provider of these symptoms and request an order for lorazepam
(Ativan).
c. Question the patient about adherence to the drug regimen.
d. Recognize that patients with schizophrenia normally present in this fashion.
ANS: B
The patient is exhibiting signs of akathisia and should be treated with an antianxiety drug. Benztropine is an anticholinergic used to combat acute dystonia. These are not signs of psychosis, so it is not necessary to question whether or not the patient is taking the medication.
A patient arrives in the emergency department with dehydration. The patient reports taking fluphenazine (Prolixin) to treat schizophrenia. The nurse notes rigid muscles and an altered mental status. The patient has a temperature of 103.6° F, a heart rate of 98 beats per minute, and a blood pressure of 90/58 mm Hg. The nurse will anticipate administering which medication?
a. Dantrolene (Dantrium)
b. Haloperidol (Haldol)
c. Propranolol (Inderal)
d. Tetrabenazine (Xenazine)
ANS: A
The patient is exhibiting signs of neuroleptic malignant syndrome (NMS). Muscle relaxants, such as dantrolene, are usually given. Haloperidol is used to treat psychosis. Propranolol is used for treating akathisia. Tetrabenazine is sometimes used to treat symptoms of tardive dyskinesia.
The parent of a young adult who has schizophrenia is concerned that the patient spits out pills that are given. The nurse will suggest contacting the patient’s provider to discuss which intervention?
a. Changing to a liquid or injectable form of the mediation
b. Providing a home health nurse to supervise medication administration
c. Teaching the patient the importance of taking the medication
d. Instruct the parent to administer another dose if they suspect the first dose wasn’t
swallowed
ANS: A
Noncompliance is common with antipsychotic medications. If patients spit out or hide pills, a liquid or injectable form can be considered. A home health nurse is costly and unnecessary. Teaching the patient the importance of the medication is essential, but not always effective if the patient does not want to take their medication. It is important not to double up on doses, so administering extra doses when it is suspected a dose was spit out would not be advised.
The nurse is preparing to administer intramuscular haloperidol (Haldol) to a patient who has schizophrenia. What action will the nurse perform?
a. Massage the site after injecting the medication to ensure complete absorption.
b. Teach the patient to return every week to receive medication doses.
c. Use a small-bore needle when injecting the medication.
d. Use the Z-track method and inject the medication into deep muscle tissue.
ANS: D
Haloperidol is a viscous liquid and should be injected deep into muscle tissue using a Z-track method. The injection site should not be massaged. Injections of long-term preparations of haloperidol are given every 2 to 4 weeks. Nurses should use a large-bore needle when injecting haloperidol.
The nurse is teaching a patient who will be discharged home on a typical antipsychotic medication to treat schizophrenia. Which statement by the patient indicates a need for further teaching?
a. “I should not drink alcohol while taking this medication.”
b. “I should use a heating pad to treat muscle spasms while taking this medication.”
c. “I should use sunscreen while taking this medication.”
d. “I will need frequent blood tests while taking this medication.”
ANS: B
Dystonia can cause muscle spasms and should be reported to the provider, who can prescribe medications to treat this adverse effect. Patients should not drink alcohol, should use sunscreen, and will need close monitoring of lab values while taking these medications.
A patient who is about to begin taking the atypical antipsychotic medication clozapine (Clozaril) is concerned about side effects. What information will the nurse include when teaching the patient about this medication?
a. “The most common side effects with this medication include dry mouth,
constipation, and urinary retention.”
b. “The most common side effects that you may experience are weight gain,
drowsiness, and headaches.”
c. “You will not experience extrapyramidal side effects with this medication.”
d. “You will not need frequent lab work while taking this medication.”
ANS: B
Weight gain, drowsiness, and headaches are common side effects of non-typical antipsychotic medications. Anticholinergic side effects are less likely than with typical antipsychotics. Extrapyramidal side effects can occur, even though they are less likely. Clozapine can cause agranulocytosis, so patients who are taking this drug require frequent monitoring.
A family member of a patient who has been taking fluphenazine (Prolixin) for 3 months calls to report that the patient is exhibiting agitation and restlessness. The nurse learns that the patient’s delusional thinking and hallucinations have stopped since taking the medication. The nurse will perform which action?
a. Reassure the family member that tolerance to these side effects will subside over time.
b. Remind the family member that complete drug effects may not occur for several more weeks.
c. Suggest that the family member contact the provider to discuss an order for a medication to help with the agitation and restlessness.
d. Tell the family member to withhold the medication and notify the patient’s provider.
ANS: C
The patient is exhibiting signs of akathisia and should receive a benzodiazepine. Patients usually do not experience tolerance to these drug side effects. The patient is experiencing resolution of symptoms. Discontinuing antipsychotics abruptly may lead to withdrawal symptoms.
A patient has been taking risperidone (Risperdal) for 2 weeks. The patient reports drowsiness and headache. What will the nurse do?
a. Counsel the patient to request changing to aripiprazole (Abilify).
b. Explain to the patient that these are common side effects of the medication.
c. Suggest that the patient have serum glucose testing.
d. Suggest that these may be signs of agranulocytosis.
ANS: B
Drowsiness and headaches are common side effects of atypical antipsychotics. It would be appropriate to counsel the patient to discuss the severity of these side effects with their provider. Changing to aripiprazole may not improve the symptoms, since this drug is in the same drug class. These symptoms do not indicate altered serum glucose levels or agranulocytosis.
The nurse is performing a medication history on a patient who reports taking lorazepam (Ativan) for the past 6 months to treat an anxiety disorder. The patient states that the medication is not working as well as it previously did. The nurse will:
a. contact the provider to discuss changing to another benzodiazepine.
b. tell the patient to double their dose.
c. suspect worsening of the anxiety disorder.
d. understand that the patient has developed tolerance to this drug
ANS: D
It is recommended that benzodiazepines be prescribed no longer than 3 or 4 months since the effectiveness lessens after 4 months as patients develop tolerance to the drug. Changing to another benzodiazepine will likely not change this, and it would be inappropriate to recommend that the patient double their dose without further evaluation. This does not indicate worsening of the underlying disorder.
A patient who is taking chlorpromazine calls the clinic to report having reddish-brown urine. What action will the nurse take?
a. Notify the provider and request orders for creatinine clearance and BUN levels.
b. Reassure the patient that this is a harmless side effect of this medication.
c. Tell the patient to come to the clinic for a urinalysis.
d. Tell the patient to discard any drug on hand and request a new prescription.
ANS: B
Aliphatic phenothiazines, such as chlorpromazine, can cause a harmless pink or red-brown urine discoloration. There is no need to evaluate renal function with creatinine clearance, BUN, or urinalysis. The discoloration does not indicate that the medication has expired.
A patient has begun taking buspirone hydrochloride (BuSpar) 7.5 mg twice daily to treat acute anxiety and calls 1 week later to report little change in symptoms. What will the nurse tell the patient?
a. “Therapeutic effects may not be evident until you have taken the medication for
several weeks.”
b. “The provider may need to increase the dose to 15 mg twice daily.”
c. “Notify the provider and request an order for another anxiolytic.”
d. “Stop taking the drug and notify the provider that it doesn’t work.”
ANS: A
Buspirone hydrochloride may not be effective until 1 to 2 weeks after continuous use. It is not necessary to increase the dose at this time.
A patient who is taking fluphenazine (Prolixin) to treat psychosis is experiencing symptoms of acute dystonia. While performing a medication history, the nurse learns that the patient takes herbal medications. Which herbal supplement would be of concern?
a. Ginkgo
b. Ginseng
c. Kava kava
d. St. John’s wort
ANS: C
Kava may increase the risk and severity of dystonia when taken with phenothiazines.
A patient is brought to the emergency department with decreased respirations and somnolence. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 80/58 mm Hg. The patient is known to take alprazolam (Xanax) to treat anxiety. Which medication will the nurse anticipate the provider to order?
a. Benztropine (Cogentin)
b. Flumazenil (Romazicon)
c. Lorazepam (Ativan)
d. Propranolol (Inderal)
ANS: B
Flumazenil is a benzodiazepine antagonist used to treat overdose of benzodiazepines. This patient is unconscious and has bradycardia and hypotension, so the antagonist medication is indicated. Benztropine is an anticholinergic used to treat acute dystonia in patients taking phenothiazines. Lorazepam is a benzodiazepine and would only intensify the symptoms. Propranolol is a beta blocker used to treat akathisia in patients taking phenothiazines.
A patient arrives in the emergency department complaining of difficulty breathing, dizziness, sweating, and heart palpitations. The patient reports having had similar episodes previously due to stress at work. The nurse will expect the provider to order which medication?
a. Flumazenil (Romazicon)
b. Haloperidol (Haldol)
c. Lorazepam (Ativan)
d. Propranolol (Inderal)
ANS: C
The patient is exhibiting signs of acute anxiety, so the anxiolytic lorazepam would be the appropriate agent of those listed to be administered. Flumazenil is a benzodiazepine antagonist, given for overdose of benzodiazepines. Haloperidol is given for acute psychosis. Propranolol is a beta blocker, used to treat akathisia in patients taking phenothiazines.
The nurse is teaching a patient about taking a benzodiazepine to treat grief-related anxiety. Which statement by the patient indicates understanding of the teaching?
a. “I may have wine with dinner to help with relaxation.”
b. “I may need to take this medication forever.”
c. “I may stop taking the medication when my symptoms go away.”
d. “I should try psychotherapy or a support group in addition to the medication.”
ANS: D
Psychotherapy or support groups should be part of therapy, with anxiolytics added as needed. Patients taking benzodiazepines should not consume alcohol. Anxiolytic medications are generally given for a limited length of time, particularly when treating grief-related anxiety. Patients should not stop the medications abruptly.
A nurse performs a medication history on a newly admitted patient. The patient reports taking amitriptyline (Elavil) 75 mg at bedtime for 6 weeks to treat depression. The patient reports having continued fatigue, lack of energy, and no improvement in mood. The nurse will contact the provider to discuss which intervention?
a. Beginning to down-taper the amitriptyline
b. Changing to a morning dose schedule
c. Giving the amitriptyline twice daily
d. Increasing the dose of amitriptyline
ANS: A The response to tricyclic antidepressants (TCAs) should occur after 2 to 4 weeks of therapy. If there is no improvement at that time, the TCA should be gradually withdrawn and an agent from another class should be prescribed. TCAs should never be stopped abruptly. TCAs cause fatigue and drowsiness, so they should be given at bedtime. Changing the dose or the dosing schedule is not indicated in this scenario.
The nurse is teaching a patient who will begin taking doxepin (Sinequan) to treat depression.
Which statement by the patient indicates a need for further teaching?
a. “I should expect results within 2 to 4 weeks.”
b. “I should increase fluids and fiber while taking this medication to avoid
constipation.”
c. “I should take care when rising from a sitting to standing position.”
d. “I will take the medication in the morning before breakfast.”
ANS: D Tricyclic antidepressants (TCAs) should begin to show effects within 1 to 4 weeks. Tricyclic antidepressants are known to cause orthostatic hypotension and constipation, so patients should be counseled on how to manage these side effects. TCAs should be taken at bedtime because of their tendency to cause drowsiness.
A patient who is taking amitriptyline (Elavil) reports constipation and dry mouth. The patient notes that these side effects are a nuisance, but not severe. The nurse will give the patient which instruction?
a. Increase fluid intake.
b. Notify the provider.
c. Request another antidepressant.
d. Stop taking the medication immediately.
ANS: A
Constipation and dry mouth are common side effects of tricyclic antidepressants (TCAs), and patients should be taught to manage these symptoms. There is no need to notify the provider or to switch medications unless the side effects become too uncomfortable. Patients should not stop taking TCAs abruptly.
A patient who has had a loss of interest in most activities, weight loss, and insomnia is diagnosed with major depressive disorder and will begin taking fluoxetine (Prozac) daily. The patient asks about the weekly dosing that a family member follows. What will the nurse tell the patient about a weekly dosing regimen?
a. It can be used after daily maintenance dosing proves effective and safe.
b. It is used after a trial of tricyclic antidepressant medication fails.
c. It is not effective for this type of depression and its symptoms.
d. It will cause more adverse effects than daily dosing regimens.
ANS: A
Before weekly dosing is begun, the patient should respond to a daily maintenance dose of 20 mg/day without serious effects. It is not necessary to undergo a trial of tricyclic antidepressants (TCAs). Weekly dosing is used for this type of depression, and although it may have some adverse effects, these are not more common than with daily dosing.
A patient has been taking sertraline (Zoloft) 20 mg/mL oral concentrate, 1 mL daily for several weeks and reports being unable to sleep well. The patient’s depressive symptoms are well managed on the current dose. What will the nurse do next?
a. Ask the patient what time of day the medication is taken.
b. Counsel the patient to take the medication at bedtime.
c. Recommend asking the provider about weekly dosing.
d. Suggest that the patient request a lower dose.
ANS: A
Selective serotonin reuptake inhibitors (SSRIs) can cause nervousness and insomnia. Patients can minimize these effects by taking the drug in the morning. The nurse should assess this with this patient. Taking the medication at bedtime will only increase the insomnia. Requesting a lower dose or changing to weekly dosing is not recommended.
A patient has been taking paroxetine (Paxil) 20 mg per day for 2 weeks and reports a decrease in libido. Which action will the nurse take?
a. Counsel the patient to take the medication with food.
b. Reassure the patient that this side effect can decrease over time.
c. Suggest that the patient discuss a lower dose with the provider. d. Tell the patient to stop taking the drug and contact the provider.
ANS: B
Sexual side effects can occur with paroxetine, but often improve or ceae after 1 to 4 weeks of use. Taking the medication with food will not improve this side effect. Lowering the dose is not indicated. Patients should not abruptly stop taking SSRIs. If the patient continues to have sexual side effects after continued use they should discuss with their provider.
A patient who has been diagnosed with social anxiety disorder will begin taking venlafaxine (Effexor). The nurse who performs a medication and dietary history will be concerned about ingestion of which substance or drug?
a. Coffee
b. Grapefruit juice
c. Oral hypoglycemic drug
d. St. John’s wort
ANS: D
The concurrent interaction of venlafaxine and St. John’s wort may increase the risk of serotonin syndrome and neuroleptic malignant syndrome. Oral hypoglycemic drugs are concerning for patients who take lithium. Coffee and grapefruit juice are to be avoided by patients who take monoamine oxidase inhibitors.
A male patient has been taking venlafaxine (Effexor) 37.5 mg daily for 2 weeks and reports an increase in blood pressure. The nurse understands that this is due to which of the following?
a. Increased serotonin levels.
b. Increased norepinephrine levels.
c. Increased dopamine levels.
d. Increased acetylcholine levels.
ANS: B
Venlafaxine is a serotonin norepinephrine reuptake inhibitor (SNRI) by reducing norepinephrine reuptake, norepinephrine levels are increased which can result in an increase in blood pressure.
A patient who has been taking a monoamine oxidase (MAO) inhibitor for several months will begin taking amoxapine (Asendin) instead of the MAO inhibitor. The nurse will counsel the patient to begin taking the amoxapine:
a. along with the MAO inhibitor for several months.
b. at least 14 days after discontinuing the MAO inhibitor.
c. the day after the last dose of the MAO inhibitor.
d. while withdrawing the MAO inhibitor over several weeks.
ANS: B
Amoxapine is an atypical antidepressant that should not be taken with MAO inhibitors and should not be used within 14 days of taking a MAO inhibitor.
A patient who has been diagnosed with depression asks why the provider has not ordered a monoamine oxidase (MAO) inhibitor to treat the disorder. The nurse will explain to the patient that MAO inhibitors:
a. are more expensive than other antidepressants.
b. are no longer approved for treating depression.
c. can cause profound hypotension.
d. require strict dietary restrictions.
ANS: D
MAO inhibitors have many food and drug interactions that can be fatal, and patients must adhere to strict dietary restrictions while taking these drugs. They are not more expensive than the newer antidepressants. They remain approved for treating depression. MAO inhibitors can cause profound hypertension in the presence of excess tyramine consumption.
A patient who takes a monoamine oxidase (MAO) inhibitor asks the nurse about taking
over-the-counter medications to treat cold symptoms. Which medication will the nurse
counsel the patient to avoid while taking a MAO inhibitor?
a. Diphenhydramine
b. Guaifenesin
c. Pseudoephedrine
d. Saline nasal spray
ANS: C
MAO inhibitors can cause hypertensive crises, which can be fatal when taken with sympathomimetic drugs such as pseudoephedrine.
A patient who has major depressive disorder has been taking fluoxetine (Prozac) 20 mg daily for 3 months and reports improved mood, less fatigue, and an increased ability to concentrate. The patient’s side effects have diminished. The only complaint from the patient is regarding the number of medications she has to take daily. What will the nurse counsel this patient to discuss with the provider?
a. Changing to once-weekly dosing
b. Decreasing the dose to 10 mg daily
c. Discontinuing the medication
d. Increasing the dose to 30 mg daily
ANS: A
Once patients have demonstrated control of symptoms with decreased side effects on the maintenance dose of 20 mg daily, patients may be considered for once-weekly dosing. The 20-mg dose is maintenance dosing, so decreasing or increasing the dose is not indicated. Patients should not stop taking the medication abruptly.
A patient who has been diagnosed with major depression disorder has been ordered to take doxepin (Sinequan). The nurse will contact the provider if the patient’s medical history reveals a history of which condition?
a. Asthma
b. Glaucoma
c. Hypertension d. Hypoglycemia
ANS: B
Antidepressants, such as doxepin, that cause anticholinergic-like symptoms are contraindicated if the patient has glaucoma.
The nurse is preparing to administer a dose of lithium (Lithobid) to a patient who has been
taking the drug as maintenance therapy to treat bipolar disorder. The nurse assesses the patient
and notes tremors and confusion. The patient’s latest serum lithium level was 2 mEq/L.
Which action will the nurse take?
a. Administer the dose.
b. Hold the dose and notify the provider.
c. Request an order for a higher dose.
d. Request an order for a lower dose.
ANS: B
The patient has symptoms of lithium toxicity, and the serum drug level is in the toxic range. The nurse should hold the dose and notify the provider.
The nurse assesses a patient who is taking lithium (Lithobid) and notes a large output of clear, dilute urine. The nurse suspects which cause for this finding?
a. Cardiovascular complications
b. Expected lithium side effects
c. Increased mania
d. Lithium toxicity
ANS: D
An increased output of dilute urine is a sign of lithium toxicity.
The nurse provides teaching for a patient who will begin taking lithium (Lithobid). Which statement by the patient indicates understanding of the teaching?
a. “I may drink tea or cola but not coffee.”
b. “I may stop taking the drug when mania symptoms subside.”
c. “I should consume a sodium-restricted diet.”
d. “I should drink 2 to 3 liters of fluid each day.”
ANS: D
Patients taking lithium should be encouraged to maintain adequate fluid intake of 2 to 3 L/day initially and then 1 to 2 L/day as maintenance. Patients should not drink any caffeine-containing drinks, including tea and cola. Patients must continue taking lithium even when symptoms subside, or else symptoms will recur. It is not necessary to consume a sodium-restricted diet.
A patient who has recently begun taking lithium (Lithobid) calls the clinic to report nausea, vomiting, anorexia, and hand tremor. What will the nurse do next?
a. Contact the provider to obtain an order for a serum lithium level.
b. Reassure the patient that these symptoms are common and transient.
c. Tell the patient that the lithium dose is probably too low.
d. Tell the patient to stop taking the medication immediately.
ANS: A
Early symptoms of lithium toxiNcity include nausea, vomiting, anorexia, and tremor. The nurse should obtain an order for a lithium level to evaluate this. Patients should be encouraged to report these symptoms if they occur. Patients should never be counseled to stop the medication abruptly.
The nurse is preparing to administer paroxetine HCl (Paxil) to a 70-year-old patient. The nurse understands that this patient may require
a. a decreased dose.
b. an increased dose.
c. every other day dosing.
d. more frequent dosing.
ANS: A
Older adults usually need a lower dose of antidepressants.
A patient who has a history of migraine headaches is diagnosed with bipolar disorder. The nurse might expect the provider to order which medication for this patient?
a. Carbamazepine (Tegretol)
b. Divalproex (Valproate)
c. Lamotrigine (Lamictal)
d. Lithium citrate (Eskalith)
ANS: B
All of these medications may be used to treat bipolar disorder, but divalproex also carries an indication for migraine prophylaxis.
The nurse is teaching a patient about foods to avoid when taking isocarboxazid (Marplan). Which foods will the nurse instruct the patient to avoid? (Select all that apply.)
a. Bananas
b. Bread
c. Eggs
d. Red wine
e. Sausage
f. Yogurt
ANS: A, D, E, F
Aged cheeses and wines are the chief foods that are prohibited. Any food containing tyramine, which has sympathomimetic effects, can cause a hypertensive crisis. This includes bananas, red wine, sausage, and yogurt.
