1. A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, No one cares about me. Im not worth anything. Which response by the nurse would be the
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1. A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, No one cares about me. Im 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. The staff here cares about you and wants to try to help you get better.
c. It is difficult for others to care about you when you repeatedly say negative things about yourself.
d. Ill sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon.
2. A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, No one cares about me anymore. Im not worth anything. Select an appropriate 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. consent to take 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) .
3. A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?
a. You look nice this morning.
b. You are wearing a new shirt.
c. I like the shirt youre wearing.
d. You must be feeling better today.
4. 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. Use of complementary therapy
d. Learning desensitization techniques
5. A priority nursing intervention for a patient diagnosed with major depressive disorder is:
a. distracting the patient from self-absorption.
b. carefully and inconspicuously observing the patient around the clock.
c. allowing the patient to spend long periods alone in self-reflection.
d. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.
6. 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.
7. A patient says to the nurse, My life does not have any happiness in it anymore. I once enjoyed holidays, but now theyre just another day. How would the nurse document the complaint?
a. Vegetative symptom
b. Anhedonia
c. Euphoria
d. Anergia
8. A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, I dont think I can keep taking these pills. They make me so, especially when I stand up. The nurse should:
a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks.
b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression.
c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient.
d. teach the patient how to use pursed-lip breathing.
9. A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. 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
10. A patient diagnosed with major depressive disorder tells the nurse, Bad things that happen are always my fault. To assist the patient in reframing this overgeneralization, the nurse should respond:
a. I really doubt that one person can be blamed for all the bad things that happen.
b. Lets look at one bad thing that happened to see if another explanation exists.
c. You are being exceptionally hard on yourself when you say those things.
d. How does your belief in fate relate to your cultural heritage?
11. A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of:
a. overinvolvement.
b. guilt and despair.
c. interest and pleasure.
d. ineffectiveness and frustration.
12. A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to:
a. avoid exposure to bright sunlight.
b. report increased suicidal thoughts.
c. restrict sodium intake to 1 g daily.
d. maintain a tyramine-free diet.
13. A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
a. Mashed potatoes, ground beef patty, corn, green beans, apple pie
b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment?
a. Supporting physiologic stability
b. Reducing disorientation and confusion
c. Monitoring pupillary responses
d. Assisting the patient to identify and test negative thoughts
15. A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. 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. consults the pharmacist when selecting over-the-counter medications.
d. can identify foods with high selenium content, which should be avoided.
16. A patients employment is terminated and major depressive disorder results. The patient says to the nurse, Im not worth the time you spend with me. Im 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
17. 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. Select the nurses most effective approach to communication.
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.
18. A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares. The nurse should advise the patient:
a. Go to the nearest emergency department immediately.
b. Do not to be alarmed. Take two aspirin and drink plenty of fluids.
c. Take one dose of the antidepressant. Come to the clinic to see the health care provider.
d. Resume taking the antidepressant for 2 more weeks, and then discontinue it again.
19. Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder 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.
20. A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, I feel like a failure. This baby is the root of my problems. The priority nursing diagnosis is:
a. Insomnia
b. Ineffective coping
c. Situational low self-esteem
d. Risk for other-directed violence
21. A patient diagnosed with major depressive disorder repeatedly tells staff members, I have cancer. Its 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
22. Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food?
a. Tomato juice
b. Orange juice
c. Hot tea
d. Milk
23. During a psychiatric assessment, the nurse observes a patients facial expressions that are without emotion. The patient says, Life feels so hopeless to me. Ive been feeling sad for several months. How should the nurse document the patients affect and mood?
a. Affect depressed; mood flat
b. Affect flat; mood depressed
c. Affect labile; mood euphoric
d. Affect and mood are incongruent
24. A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should:
a. avoid forcing the issue.
b. bring up the issue at the community meeting.
c. calmly tell the patient, You must bathe daily.
d. firmly and neutrally assist the patient with showering.
25. A patient was started on escitalopram (Lexapro) 5 days ago and now says, This medicine isnt working. The nurses best intervention would be to:
a. discuss with the health care provider the need to change medications.
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 symptom relief.
26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate?
a. Arms crossed
b. Staring at the nurse
c. Smiling inappropriately
d. Eyes pointed downward
27. A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. 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. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.
b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities.
c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet.
d. The patient needs time to reorient himself or herself to a pressured work schedule.
28. A nurse instructs a patient taking a drug 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.
A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. 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 deficit and sad mood
A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then 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. Labile and euphoric
b. Irritable and belligerent
c. Highly suspicious and arrogant
d. Excessively happy and confident
A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Ineffective therapeutic regimen management
A patient diagnosed with bipolar disorder is hyperactive and manic 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?"
This nursing diagnosis applies to a patient experiencing 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 the most 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 mealtime within 1 week.
d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.
A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will:
a. minimize the side effects of lithium.
b. bring hyperactivity under rapid control.
c. enhance the antimanic actions of lithium.
d. provide long-term control of hyperactivity.
A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?
a. phenytoin (Dilantin)
b. clonidine (Catapres)
c. carbamazepine (Tegretol)
d. chlorpromazine (Thorazine)
The cause of bipolar disorder has not been determined, but:
a. several factors, including genetics, are implicated.
b. brain structures were altered by stresses early in life.
c. excess norepinephrine is probably a major factor.
d. excess sensitivity in dopamine receptors may exist.
The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's best response.
a. "A high proportion of patients diagnosed with bipolar disorders are found among creative writers."
b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder."
c. "Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses."
d. "More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds."
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. Select the best initial approach by the nurse.
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."
A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is:
a. within therapeutic limits
b. below therapeutic limits
c. above therapeutic limits
d. incorrect because of inaccurate testing
Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group?
a. clonazepam (Klonopin)
b. risperidone (Risperdal)
c. lamotrigine (Lamictal)
d. aripiprazole (Abilify)
When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority?
a. Allow the patient to act out his or her feelings.
b. Set limits on the patient's behavior as necessary.
c. Provide verbal instructions to the patient to remain calm.
d. Restrain the patient to reduce hyperactivity and aggression.
At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option.
a. 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
A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action?
a. Confer with the health care provider regarding use of seclusion for this patient.
b. Hold a staff meeting to discuss consistency and limit-setting approaches.
c. Conduct a meeting with all patients to discuss the behavior.
d. Explain to the patient that the behavior is unacceptable.
A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to:
a. quietly ask the patient, "Why don't you put on your clothes?"
b. firmly tell the patient, "Stop dancing, and put on your clothing."
c. put a blanket around the patient, and walk with the patient to a quiet room.
d. allow the patient stay in the group room. Move the other patients to a different area.
A patient experiencing acute mania 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 most appropriate intervention.
a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit.
b. Invite the patient to sit with the nurse and look at new fashion magazines.
c. Tell the patient that computer use is not allowed until self-control improves.
d. Ask whether the patient has enough money to pay for the purchases.
A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with:
a. meals.
b. an antacid.
c. a large glass of juice.
d. an antiemetic medication.
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 fluids.
c. double the lithium dose if diarrhea or vomiting occurs.
d. avoid eating aged cheese, processed meats, and red wine
Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania?
a. Deficient diversional activity
b. Disturbed sleep pattern
c. Fluid volume excess
d. Defensive coping
Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania?
a. Spaghetti and meatballs, salad, a banana
b. Beef and vegetable stew, a roll, chocolate pudding
c. Broiled chicken breast on a roll, an ear of corn, apple
d. Chicken casserole, green beans, flavored gelatin with whipped cream
Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on:
a. maintaining an interest in the environment.
b. developing an optimistic outlook.
c. self-control of distorted thinking.
d. stabilizing the sleep pattern.
Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective?
a. "Converses without interrupting; 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."
A patient experiencing 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 physiologic functioning
b. Provide a subdued environment
c. Supervise personal hygiene
d. Observe for mood changes
A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention?
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.
A patient experiencing 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.
A patient experiencing acute mania is dancing atop the 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." The nurse's first intervention is to:
a. tell the patient, "You need to be secluded."
b. help the patient down from the table.
c. clear the room of all other patients.
d. assemble a show of force.
After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family?
a. Decreasing physical activity
b. Increasing food and fluids
c. Meeting self-care needs
d. Psychoeducation
A patient receiving lithium should be assessed for which evidence of complications?
a. Pharyngitis, mydriasis, and dystonia
b. Alopecia, purpura, and drowsiness
c. Diaphoresis, weakness, and nausea
d. Ascites, dyspnea, and edema
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 most appropriate response.
a. "You will be able to stop the medication in approximately 1 month."
b. "Taking the medication every day helps prevent relapses and recurrences."
c. "Usually patients take this medication for approximately 6 months after discharge."
d. "It's unusual that the health care provider has not already stopped your medication."
A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient:
a. "Restrict oral fluids for 24 hours and stay in bed."
b. "Have someone bring you to the clinic immediately."
c. "Drink a large glass of water with 1 teaspoon of salt added."
d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."
Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical?
a. Arthritis
b. Epilepsy
c. Psoriasis
d. Congestive heart failure
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 best response.
a. "Why are you laughing?"
b. "Please share the joke with me."
c. "I don't think I said anything funny."
d. "You are laughing. Tell me what's happening."
A person diagnosed with schizophrenia has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me." 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 if you will let them."
d. "Staff members are health care professionals who are qualified to help you."
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.
A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to overdose me." How does this patient perceive the environment?
a. Disorganized
b. Unpredictable
c. Dangerous
d. Bizarre
When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse 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
A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the health care provider?
a. Use of a long-acting antipsychotic injections
b. Addition of a benzodiazepine, such as lorazepam (Ativan)
c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil)
d. Inpatient hospitalization because of the high risk for exacerbation of symptoms
A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?
a. Aloofness, haughtiness, suspicion
b. Darting eyes, tilted head, mumbling to self
c. Elevated mood, hyperactivity, distractibility
d. Performing rituals, avoiding open places
A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate?
a. clozapine (Clozaril)
b. ziprasidone (Geodon)
c. olanzapine (Zyprexa)
d. aripiprazole (Abilify)
A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best 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."
A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance?
a. Psychosocial
b. Physiologic
c. Self-actualization
d. Safety and security
A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is 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. voluntarily accept tube feeding by day 2.
A nurse observes a patient who is diagnosed with schizophrenia. The patient is 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
Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning?
a. 39 years old; paranoid ideation since age 35 years
b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years
c. 19 years old; diagnosed with schizophreniform disorder 6 months ago
d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed
A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?
a. Allow the patient to have supervised access to food vending machines
b. Allow the patient to telephone a local restaurant to deliver meals
c. Offer to taste each portion on the tray for the patient
d. Begin tube feedings or total parenteral nutrition
A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan.
a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.
b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences.
c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes.
d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.
Patients diagnosed with schizophrenia who are suspicious and withdrawn:
a. universally fear sexual involvement with therapists.
b. are socially disabled by the positive symptoms of schizophrenia.
c. exhibit a high degree of hostility as evidenced by rejecting behavior.
d. avoid relationships because they become anxious with emotional closeness.
A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm 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 will stay with you. Focus on what we are talking about, not the voices."
d. "Forget the voices. Ask some other patients to sit and talk with you."
A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms?
a. Neuroleptic malignant syndrome
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia
A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), 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 is thrust forward, and the patient is drooling. Which problem is most likely?
a. Acute dystonic reaction
b. Tardive dyskinesia
c. Waxy flexibility
d. Akathisia
An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated?
a. Administer diphenhydramine (Benadryl) 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 (Artane) 5 mg orally at the next regularly scheduled medication administration time.
d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.
A patient has taken trifluoperazine (Stelazine) 30 mg/day orally 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 syndrome
d. Anticholinergic effects
Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization?
a. Extremes of motor activity, from excitement to stupor
b. Social withdrawal and ineffective communication
c. Severe anxiety with ritualistic behavior
d. Highly suspicious, delusional behavior
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
A patient diagnosed with schizophrenia says, "Everyone has skin lice that jump on you and contaminate your blood." Which problem is evident?
a. Poverty of content
b. Concrete thinking
c. Neologisms
d. Paranoia
A patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, "You are mean and nasty. No one trusts you or wants to be around you." Select the most likely analysis. The patient:
a. is trying to manipulate the nurse by using negative comments.
b. is likely to experience disorganization and catatonia in the near future.
c. is jealous of the nurse's position of power in the relationship.
d. may be identifying another person's shortcomings in order to preserve his or her own self-esteem.
A patient diagnosed with schizophrenia says, "High heat. Last time here. Did you get a coat?" What type of verbalization is evident?
a. Neologism
b. Idea of reference
c. Thought broadcasting
d. Associative looseness
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 expects a change to which medication?
a. haloperidol (Haldol)
b. olanzapine (Zyprexa)
c. chlorpromazine (Thorazine)
d. diphenhydramine (Benadryl)
The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend?
a. Psychoeducational
b. Psychoanalytic
c. Transactional
d. Family
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, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as an indication of:
a. need for psychoeducation
b. medication noncompliance
c. chronic deterioration
d. relapse
A patient diagnosed with schizophrenia begins to talks about "cracklomers" in the local shopping mall. The term "cracklomers" should be documented as:
a. neologism.
b. concrete thinking.
c. thought insertion.
d. an idea of reference.
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.
A patient diagnosed with schizophrenia has auditory hallucinations. The patient 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. "Do the messages from the voice frighten you?"
c. "Do you recognize the voice speaking to you?"
d. "What is the voice telling you to do?"
A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. 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, low fat diet.
d. Neuroleptic malignant syndrome. Immediately notify the health care provider.
A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5'2' tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication?
a. How to recognize tardive dyskinesia
b. Weight management strategies
c. Ways to manage constipation
d. Sleep hygiene measures
A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. 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. Motor agitation
An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of:
a. delirium.
b. dementia.
c. amnestic syndrome.
d. Alzheimer disease.
A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing?
a. Aphasia
b. Dystonia
c. Tactile hallucinations
d. Mnemonic disturbance
A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?
a. "There are no bugs on your legs. Your imagination is playing tricks on you."
b. "Try to relax. The crawling sensation will go away sooner if you can relax."
c. "Don't worry. I will have someone stay here and brush off the bugs for you."
d. "I don't see any bugs, but I know you are frightened so I will stay with you."
What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks
b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait
c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations
d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
a. Avoidance of physical contact
b. High level of sensory stimulation
c. Careful observation and supervision
d. Application of wrist and ankle restraints
Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations?
a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on.
b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status.
c. Maintain soft lighting day and night. Keep a radio on low volume continuously.
d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
Which description best applies to a hallucination? A patient:
a. looks at shadows on a wall and says, "I see scary faces."
b. states, "I feel bugs crawling on my legs and biting me."
c. becomes anxious when the nurse leaves his or her bedside.
d. tries to hit the nurse when vital signs are taken.
Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems?
a. Intoxication
b. Dementia
c. Delirium
d. Amnesia
When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase?
a. donepezil (Aricept)
b. rivastigmine (Exelon)
c. memantine (Namenda)
d. galantamine (Razadyne)
An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
a. Aphasia
b. Apraxia
c. Agnosia
d. Memory impairment
An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer disease was subsequently diagnosed. Which stage of Alzheimer disease is evident?
a. 1 (mild)
b. 2 (moderate)
c. 3 (moderate to severe)
d. 4 (late)
Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group?
a. Alzheimer disease
b. Wernicke encephalopathy
c. Central anticholinergic syndrome
d. Acquired immunodeficiency syndrome (AIDS)-related dementia
A patient diagnosed with stage 1 Alzheimer disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?
a. Risk for injury
b. Impaired memory
c. Self-care deficit
d. Caregiver role strain
A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment?
a. Assist the patient to perform simple tasks by giving step-by-step directions.
b. Reduce frustration by performing activities of daily living for the patient.
c. Stimulate intellectual function by discussing new topics with the patient.
d. Promote the use of the patient's sense of humor by telling jokes.
Two patients in a residential care facility are diagnosed with dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "I know what you're up to; you're trying to steal my car." What is the nurse's best action?
a. Administer one dose of an antipsychotic medication to both patients.
b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection."
c. Separate and distract the patients. Take one to the day room and the other to an activities area.
d. Step between the two patients and say, "Please quiet down. We do not allow violence here."
An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful?
a. Place large clocks and calendars on the wall.
b. Place personally meaningful objects in view.
c. Use the patient's glasses and hearing aids.
d. Keep the room brightly lit at all times.
A patient diagnosed with stage 2 Alzheimer disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as:
a. hyperorality.
b. aphasia.
c. apraxia.
d. agnosia.
During morning care, a nursing assistant asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response?
a. Sundown syndrome
b. Confabulation
c. Perseveration
d. Delirium
A patient diagnosed with Alzheimer disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety?
a. Place throw rugs on tile or wooden floors.
b. Place locks at the tops of doors.
c. Encourage daytime napping.
d. Obtain a bed with side rails.
Goals and outcomes for an older adult patient experiencing delirium caused by fever and dehydration will focus on:
a. returning to premorbid levels of function.
b. identifying stressors negatively affecting self.
c. demonstrating motor responses to noxious stimuli.
d. exerting control over responses to perceptual distortions.
An older adult diagnosed with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family?
a. Label the bathroom door.
b. Take the older adult to the bathroom hourly.
c. Place the older adult in disposable adult diapers.
d. Make sure the older adult does not eat nonfood items.
A patient diagnosed with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply?
a. "Your family member will never again be able to identify you."
b. "I think that is a question the health care provider should answer."
c. "One never knows. Consciousness fluctuates in persons with dementia."
d. "It is disappointing when someone you love no longer recognizes you."
A patient diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members?
a. Wear large name tags.
b. Focus interaction on familiar topics.
c. Frequently repeat the reorientation strategies.
d. Strategically place large clocks and calendars.
What is the priority need for a patient diagnosed with late-stage dementia?
a. Promotion of self-care activities
b. Meaningful verbal communication
c. Maintenance of nutrition and hydration
d. Prevention of the patient from wandering
Which intervention is appropriate to use for patients diagnosed with either delirium or dementia?
a. Speak in a loud, firm voice.
b. Touch the patient before speaking.
c. Reintroduce the health care worker at each contact.
d. When the patient becomes aggressive, use physical restraint instead of medication.
A hospitalized patient experiencing delirium misinterprets reality, and a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will:
a. remain safe in the environment.
b. participate actively in self-care.
c. communicate verbally.
d. acknowledge reality.
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped)
b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
c. About 0200 on hospital day 3 (72 hours after drinking stopped)
d. About 0200 on hospital day 4 (96 hours after drinking stopped)
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is:
a. jaundiced.
b. dependent on alcohol.
c. healthy but underweight.
d. microcephalic and cognitively impaired.
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing:
a. an illusion.
b. a delusion.
c. hallucinations.
d. hypnagogic phenomenon
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Snakes are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the situation? The patient:
a. is attempting to obtain attention by manipulating staff.
b. may have sustained a head injury before admission.
c. has symptoms of alcohol withdrawal delirium.
d. is having a recurrence of an acute psychosis.
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
a. Disturbed sensory perception
b. Ineffective coping
c. Ineffective denial
d. Risk for injury
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe?
a. Monoamine oxidase inhibitor, such as phenelzine (Nardil)
b. Phenothiazine, such as thioridazine (Mellaril)
c. Benzodiazepine, such as lorazepam (Ativan)
d. Narcotic analgesic, such as morphine
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
a. Check the patient every 15 minutes.
b. Rigorously encourage fluid intake.
c. Provide one-on-one supervision.
d. Keep the room dimly lit.
A patient with a history of daily alcohol abuse says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more objectively?
a. "Sooner or later, alcohol will kill you. Then what will happen to your children?"
b. "I hear a lot of defensiveness in your voice. Do you really believe this?"
c. "If you were coping so well, why were you hospitalized again?"
d. "Tell me what happened the last time you drank."
A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse's best response?
a. "It is a self-help group with the goal of sobriety."
b. "It is a form of group therapy led by a psychiatrist."
c. "It is a group that learns about drinking from a group leader."
d. "It is a network that advocates strong punishment for drunk drivers."
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient:
a. rarely drinks alcohol.
b. has a high tolerance to alcohol.
c. has been treated with disulfiram (Antabuse).
d. has recently ingested both alcohol and sedative drugs.
A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." The patient is using which defense mechanism?
a. Rationalization
b. Introjection
c. Projection
d. Denial
A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly?
a. "I see," and use interested silence.
b. "I think you may be drinking more than you report."
c. "Being a social drinker involves having a drink or two once or twice a week."
d. "You describe drinking steadily throughout the day and evening. Am I correct?"
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse?
a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it."
b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol."
c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection."
d. "Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouse's behavior carefully."
The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?
a. Consider each disorder primary and provide simultaneous treatment.
b. The person will benefit from treatment in a residential treatment facility.
c. Withdraw the person from cannabis, and then treat the schizophrenia.
d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
When working with a patient beginning treatment for alcohol abuse, what is the nurse's most therapeutic approach?
a. Empathetic, supportive
b. Strong, confrontational
c. Skeptical, guarded
d. Cool, distant
A patient comes to an outpatient appointment obviously intoxicated. The nurse should:
a. explore the patient's reasons for drinking today.
b. arrange admission to an inpatient psychiatric unit.
c. coordinate emergency admission to a detoxification unit.
d. tell the patient, "We cannot see you today because you've been drinking."
When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur?
a. Tolerance develops.
b. The alcohol is less potent.
c. Antagonistic effects occur.
d. Hypomagnesemia develops.
Which statement most accurately describes substance addiction?
a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped.
b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters.
c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects.
d. It involves using a combination of substances to weaken or inhibit the effect of another drug.
A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct?
a. The patient is exhibiting a prodromal symptom of seizures.
b. An idiosyncratic reaction to naloxone is occurring.
c. Symptoms of opiate withdrawal are present.
d. The patient is experiencing a relapse.
In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department.
c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
d. The patient will identify two community resources for the treatment of substance abuse by discharge.
Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose.
a. Monitor the airway and vital signs every 15 minutes.
b. Insert a nasogastric tube and test gastric pH.
c. Treat hyperpyrexia with cooling measures.
d. Insert an indwelling urinary catheter.
A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident?
a. Accepting responsibility for medication errors.
b. Seeking to be assigned as a medication nurse.
c. Frequent complaints of physical pain.
d. High sociability with peers.
A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling?
a. Conveying understanding that pressures associated with nursing practice underlie substance abuse.
b. Pointing out that work problems are the result, but not the cause, of substance abuse.
c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing.
d. Providing health teaching about stress management.
Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed?
a. One-week detoxification program
b. Long-term outpatient therapy
c. Twelve-step self-help program
d. Residential program
Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis?
a. Powerlessness
b. Disturbed thought processes
c. Ineffective thermoregulation
d. Impaired oral mucous membrane
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
a. Make physical contact by frequently touching the patient.
b. Offer intellectual activities requiring concentration.
c. Avoid manipulation by denying the patient's requests.
d. Observe for depression and suicidal ideation.
Which assessment findings best correlate to the withdrawal from central nervous system depressants?
a. Dilated pupils, tachycardia, elevated blood pressure, elation
b. Labile mood, lack of coordination, fever, drowsiness
c. Nausea, vomiting, diaphoresis, anxiety, tremors
d. Excessive eating, constipation, headache
A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
a. Substance abuse
b. Substance addiction
c. Substance intoxication
d. Recreational use of a social drug
Which assessment findings will the nurse expect in an individual who has just injected heroin?
a. Anxiety, restlessness, paranoid delusions
b. Heightened sexuality, insomnia, euphoria
c. Muscle aching, dilated pupils, tachycardia
d. Drowsiness, constricted pupils, slurred speech
A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for:
a. slurred speech, excessive drowsiness, and bradycardia.
b. paranoid delusions, tactile hallucinations, and panic.
c. runny nose, yawning, insomnia, and chills.
d. anxiety, agitation, and aggression.
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "pentobarbital sodium." What is the nurse's first action?
a. Test reflexes
b. Check pupils
c. Initiate vomiting
d. Establish a patent airway
An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a:
a. cocaine overdose.
b. schizophrenic episode.
c. phencyclidine (PCP) intoxication.
d. D-lysergic acid diethylamide (LSD) ingestion.
In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)?
a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided.
b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained.
c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided.
d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect:
a. acrophobia.
b. hypothermia.
c. hallucinations.
d. anterograde amnesia.
A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug?
a. The drug's metabolism is stimulated.
b. The drug's effect is diminished.
c. A synergistic effect occurs.
d. There is no effect.
Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction?
a. methadone (Dolophine)
b. bromocriptine (Parlodel)
c. disulfiram (Antabuse)
d. naltrexone (Revia)
Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will
a. use rationalization in healthy ways.
b. state, "I see the need for ongoing treatment."
c. identify constructive outlets for expression of anger.
d. develop a trusting relationship with one staff member.
Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
a. "Have you ever had blackouts?"
b. "When did you have your last drink?"
c. "Has drinking caused you any problems?"
d. "When did you decide to seek treatment?"
A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies?
a. Chronic low self-esteem
b. Situational low self-esteem
c. Disturbed personal identity
d. Ineffective health maintenance
Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective?
a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks.
b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history.
c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company."
d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."
Which assessment findings support a nurse's suspicion that a patient has been using inhalants?
a. Pinpoint pupils and respiratory rate of 12 breaths per minute
b. Perforated nasal septum and hypertension
c. Drowsiness, euphoria, and constipation
d. Confusion, mouth ulcers, and ataxia
Multiple Choice
1. 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
2. A student nurse caring for a patient diagnosed with major depressive disorder reads in the patients medical record, This patient shows vegetative signs of depression. Which nursing diagnoses most clearly relate to the vegetative signs? 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
3. A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply.
a. Administer pretreatment medication 30 to 45 minutes before treatment.
b. Withhold food and fluids for a minimum of 6 hours before treatment.
c. Remove dentures, glasses, contact lenses, and hearing aids.
d. Restrain the patient in bed with padded limb restraints.
e. Assist the patient to prepare an advance directive.
4. 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 the intake of processed foods.
5. A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, I took a few extra tablets earlier in the day and now I feel bad. Which aspects of the nursing assessment are most critical? Select all that apply.
a. Vital signs
b. Urinary frequency
c. Increased suicidal ideation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness
A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply.
a. Provide structure
b. Limit credit card access
c. Encourage group social interaction
d. Limit work to half days
e. Monitor the patient's sleep patterns
A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply.
a. Imbalanced nutrition: more than body requirements
b. Disturbed thought processes
c. Sleep deprivation
d. Chronic confusion
e. Social isolation
A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such 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
The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply.
a. Neurobiological
b. Environmental
c. Family theory
d. Genetic
e. Stress
A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority?
a. How to complete an application for employment
b. The importance of correctly taking your medication
c. How to dress when attending community events
d. How to give and receive compliments
e. Ways to quit smoking
A patient diagnosed with schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to assault 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
A patient diagnosed with Alzheimer disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient's plan of care. Select all that apply.
a. Provide clothing with elastic and hook-and-loop closures.
b. Label clothing with the patient's name and name of the item.
c. Administer antianxiety medication before bathing and dressing.
d. Provide necessary items, and direct the patient to proceed independently.
e. If the patient resists, use distraction and then try again after a short interval.
Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply.
a. Impaired level of consciousness
b. Disorientation to place and time
c. Wandering attention
d. Apathy
e. Agnosia
A nurse should anticipate that which symptoms of Alzheimer disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply.
a. Agraphia
b. Hyperorality
c. Fine motor tremors
d. Hypermetamorphosis
e. Improvement of memory
A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply.
a. Avoid aged cheeses.
b. Read labels of all liquid medications.
c. Wear sunscreen and avoid bright sunlight.
d. Maintain an adequate dietary intake of sodium.
e. Avoid breathing fumes of paints, stains, and stripping compounds.
A nurse can assist a patient diagnosed with addiction and the patient's family in which aspects of relapse prevention? Select all that apply.
a. Rehearsing techniques to handle anticipated stressful situations
b. Advising the patient to accept residential treatment if relapse occurs
c. Assisting the patient to identify life skills needed for effective coping
d. Isolating self from significant others and social situations until sobriety is established
e. Teaching the patient about the physical changes to expect as the body adapts to functioning without substances
While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply.
a. Administration of naloxone (Narcan)
b. Vitamin B12 and folate supplements
c. Restoring nutritional integrity
d. Prevention of seizures
e. Reduction of fever
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