PART 1

1. Marco approached Nurse Trish asking for advice on how to deal with his alcohol addiction. Nurse Trish should tell the client that the only effective treatment for alcoholism is: 

A. PsychotherapyB. Alcoholics anonymous (A.A.)C. Total abstinenceD. Aversion Therapy 

2.Nurse Hazel is caring for a male client who experience false sensory perceptions with no basis in reality. This perception is known as: 

A. HallucinationsB. DelusionsC. Loose associationsD. Neologisms 

3. Nurse Monet is caring for a female client who has suicidal tendency. When accompanying the client to the restroom, Nurse Monet should… 

A. Give her privacyB. Allow her to urinateC. Open the window and allow her to get some fresh airD. Observe her 

4. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa. Which action should the nurse include in the plan? 

A. Provide privacy during mealsB. Set-up a strict eating plan for the clientC. Encourage client to exercise to reduce anxietyD. Restrict visits with the family 

5. A client is experiencing anxiety attack. The most appropriate nursing intervention should include? 

A. Turning on the televisionB. Leaving the client aloneC. Staying with the client and speaking in short sentencesD. Ask the client to play with other clients 

6. A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is: 

A. Being KilledB. Highly famous and important

C. Responsible for evil worldD. Connected to client unrelated to oneself 

7.A 20 year old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping? 

A. Recurrent self-destructive behaviorB. Avoiding relationshipC. Showing interest in solitary activitiesD. Inability to make choices and decision without advise 

8. A male client is diagnosed with schizotypal personality disorder. Which signs would this client exhibit during social situation? 

A. Paranoid thoughtsB. Emotional affectC. Independence needD. Aggressive behavior 

9. Nurse Claire is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is? 

A. Encourage to avoid foodsB. Identify anxiety causing situationsC. Eat only three meals a dayD. Avoid shopping plenty of groceries 

10. Nurse Tony was caring for a 41 year old female client. Which behavior by the client indicates adult cognitive development? 

A. Generates new levels of awarenessB. Assumes responsibility for her actionsC. Has maximum ability to solve problems and learn new skillsD. Her perception are based on reality 

11. A neuromuscular blocking agent is administered to a client before ECT therapy. The Nurse should carefully observe the client for? 

A. Respiratory difficultiesB. Nausea and vomitingC. DizzinessD. Seizures 

12. A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be? 

A. Apathetic response to the environmentB. “I don’t know” answer to questionsC. Shallow of labile effectD. Neglect of personal hygiene 

13. Nurse Trish is working in a mental health facility; the nurse priority nursing intervention for a newly admitted client with bulimia nervosa would be to? 

A. Teach client to measure I & OB. Involve client in planning daily mealC. Observe client during mealsD. Monitor client continuously 

14. Nurse Patricia is aware that the major health complication associated with intractable anorexia nervosa would be? 

A. Cardiac dysrhythmias resulting to cardiac arrestB. Glucose intolerance resulting in protracted hypoglycemiaC. Endocrine imbalance causing cold amenorrheaD. Decreased metabolism causing cold intolerance 

15. Nurse Anna can minimize agitation in a disturbed client by? 

A. Increasing stimulationB. limiting unnecessary interactionC. increasing appropriate sensory perceptionD. ensuring constant client and staff contact 

16. A 39 year old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often: 

A. Problems with being too conscientiousB. Problems with anger and remorseC. Feelings of guilt and inadequacyD. Feeling of unworthiness and hopelessness 

17. Mario is complaining to other clients about not being allowed by staff to keep food in his room. Which of the following interventions would be most appropriate? 

A. Allowing a snack to be kept in his roomB. Reprimanding the clientC. Ignoring the clients behaviorD. Setting limits on the behavior 

18. Conney with borderline personality disorder who is to be discharge soon threatens to “do something” to herself if discharged. Which of the

following actions by the nurse would be most important? 

A. Ask a family member to stay with the client at home temporarilyB. Discuss the meaning of the client’s statement with herC. Request an immediate extension for the clientD. Ignore the clients statement because it’s a sign of manipulation 

19. Joey a client with antisocial personality disorder belches loudly. A staff member asks Joey, “Do you know why people find you repulsive?” this statement most likely would elicit which of the following client reaction? 

A. DefensivenessB. EmbarrassmentC. ShameD. Remorsefulness 

20. Which of the following approaches would be most appropriate to use with a client suffering from narcissistic personality disorder when discrepancies exist between what the client states and what actually exist? 

A. RationalizationB. Supportive confrontationC. Limit settingD. Consistency 

21. Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis and hyperactivity. Blood pressure is 190/87 mmhg and pulse is 92 bpm. Which of the medications would the nurse expect to administer? 

A. Naloxone (Narcan)B. Benzlropine (Cogentin)C. Lorazepam (Ativan)D. Haloperidol (Haldol) 

22. Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal? 

A. MilkB. Orange JuiceC. SodaD. Regular Coffee 

23. Which of the following would Nurse Hazel expect to assess for a client who is exhibiting late signs of heroin withdrawal? 

A. Yawning & diaphoresisB. Restlessness & IrritabilityC. Constipation & steatorrheaD. Vomiting and Diarrhea 

24. To establish open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should? 

A. Encourage the staff to have frequent interaction with the clientB. Share an activity with the clientC. Give client feedback about behaviorD. Respect client’s need for personal space 

25. Nurse Monette recognizes that the focus of environmental (MILIEU) therapy is to: 

A. Manipulate the environment to bring about positive changes in behaviorB. Allow the client’s freedom to determine whether or not they will be involved in activitiesC. Role play life events to meet individual needsD. Use natural remedies rather than drugs to control behavior 

26. Nurse Trish would expect a child with a diagnosis of reactive attachment disorder to: 

A. Have more positive relation with the father than the motherB. Cling to mother & cry on separationC. Be able to develop only superficial relation with the othersD. Have been physically abuse 

27. When teaching parents about childhood depression Nurse Trina should say? 

A. It may appear acting out behaviorB. Does not respond to conventional treatmentC. Is short in duration & resolves easilyD. Looks almost identical to adult depression 

28. Nurse Perry is aware that language development in autistic child resembles: 

A. Scanning speechB. Speech lagC. ShutteringD. Echolalia 

29. A 60 year old female client who lives alone tells the nurse at the community health center “I really don’t need anyone to talk to”. The TV is my best friend. 

The nurse recognizes that the client is using the defense mechanism known as? 

A. DisplacementB. ProjectionC. SublimationD. Denial 

30. When working with a male client suffering phobia about black cats, Nurse Trish should anticipate that a problem for this client would be? 

A. Anxiety when discussing phobiaB. Anger toward the feared objectC. Denying that the phobia existD. Distortion of reality when completing daily routines 

31. Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda’s anxiety. The most therapeutic question by the nurse would be? 

A. Would you like to watch TV?B. Would you like me to talk with you?C. Are you feeling upset now?D. Ignore the client 

32. Nurse Penny is aware that the symptoms that distinguish post traumatic stress disorder from other anxiety disorder would be: 

A. Avoidance of situation & certain activities that resemble the stressB. Depression and a blunted affect when discussing the traumatic situationC. Lack of interest in family & othersD. Re-experiencing the trauma in dreams or flashback 

33. Nurse Benjie is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information. Nurse Benjie is aware that this is typical of? 

A. Flight of ideasB. Associative loosenessC. ConfabulationD. Concretism 

34. Nurse Joey is aware that the signs & symptoms that would be most specific for diagnosis anorexia are? 

A. Excessive weight loss, amenorrhea & abdominal distensionB. Slow pulse, 10% weight loss & alopecia

C. Compulsive behavior, excessive fears & nauseaD. Excessive activity, memory lapses & an increased pulse 

35. A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia would be: 

A. Frequent regurgitation & re-swallowing of foodB. Previous history of gastritisC. Badly stained teethD. Positive body image 

36. Nurse Monette is aware that extremely depressed clients seem to do best in settings where they have: 

A. Multiple stimuliB. Routine ActivitiesC. Minimal decision makingD. Varied Activities 

37. To further assess a client’s suicidal potential. Nurse Katrina should be especially alert to the client expression of: 

A. Frustration & fear of deathB. Anger & resentmentC. Anxiety & lonelinessD. Helplessness & hopelessness 

38. A nursing care plan for a male client with bipolar I disorder should include: 

A. Providing a structured environmentB. Designing activities that will require the client to maintain contact with realityC. Engaging the client in conversing about current affairsD. Touching the client provide assurance 

39. When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual: 

A. Helps the client focus on the inability to deal with realityB. Helps the client control the anxietyC. Is under the client’s conscious controlD. Is used by the client primarily for secondary gains 

40. A 32 year old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will

demonstrate: 

A. Low self esteemB. Concrete thinkingC. Effective self boundariesD. Weak ego 

41. A 23 year old client has been admitted with a diagnosis of schizophrenia says to the nurse “Yes, its march, March is little woman”. That’s literal you know”. These statement illustrate: 

A. NeologismsB. EcholaliaC. Flight of ideasD. Loosening of association 

42. A long term goal for a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs would be to help the client develop: 

A. Insight into his behaviorB. Better self controlC. Feeling of self worthD. Faith in his wife 

43. A male client who is experiencing disordered thinking about food being poisoned is admitted to the mental health unit. The nurse uses which communication technique to encourage the client to eat dinner? 

A. Focusing on self-disclosure of own food preferenceB. Using open ended question and silenceC. Offering opinion about the need to eatD. Verbalizing reasons that the client may not choose to eat 

44. Nurse Nina is assigned to care for a client diagnosed with Catatonic Stupor. When Nurse Nina enters the client’s room, the client is found lying on the bed with a body pulled into a fetal position. Nurse Nina should? 

A. Ask the client direct questions to encourage talkingB. Rake the client into the dayroom to be with other clientsC. Sit beside the client in silence and occasionally ask open-ended questionD. Leave the client alone and continue with providing care to the other clients 

45. Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the

client? 

A. “You’re having hallucination, there are no spiders in this room at all”B. “I can see the spiders on the wall, but they are not going to hurt you”C. “Would you like me to kill the spiders”D. “I know you are frightened, but I do not see spiders on the wall” 

46. Nurse Jonel is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information? 

A. “Abuse occurs more in low-income families”B. “Abuser Are often jealous or self-centered”C. “Abuser use fear and intimidation”D. “Abuser usually have poor self-esteem” 

47. During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because? 

A. Anesthesia is administered during the procedureB. Decrease oxygen to the brain increases confusion and disorientationC. Grand mal seizure activity depresses respirationsD. Muscle relaxations given to prevent injury during seizure activity depress respirations. 

48. When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation? 

A. The client eliminates all anxiety from daily situationsB. The client ignores feelings of anxietyC. The client identifies anxiety producing situationsD. The client maintains contact with a crisis counselor 

49. Nurse Tina is caring for a client with depression who has not responded to antidepressant medication. The nurse anticipates that what treatment procedure may be prescribed? 

A. Neuroleptic medicationB. Short term seclusionC. PsychosurgeryD. Electroconvulsive therapy 

50. Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in

charge should obtain initially is the: 

A. Length of time on the med.B. Name of the ingested medication & the amount ingestedC. Reason for the suicide attemptD. Name of the nearest relative & their phone number

PART 1 ANSWERS

1. C. Total abstinence is the only effective treatment for alcoholism.

2. A. Hallucinations are visual, auditory, gustatory, tactile or olfactory perceptions that have no basis in reality.

3. D. The Nurse has a responsibility to observe continuously the acutely suicidal client. The Nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death.

4. B. Establishing a consistent eating plan and monitoring client’s weight are important to this disorder.

5. C. Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.

6. B. Delusion of grandeur is a false belief that one is highly famous and important.

7. D. Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

8. A. Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.

9. B. Bulimia disorder generally is a maladaptive coping response to stress and underlying issues. The client should identify anxiety causing situation that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.

10. A. An adult age 31 to 45 generates new level of awareness.

11. A. Neuromuscular Blocker, such as SUCCINYLCHOLINE (Anectine) produces respiratory depression because it inhibits contractions of respiratory muscles.

12. C. With depression, there is little or no emotional involvement therefore little alteration in affect.

13. D. These clients often hide food or force vomiting; therefore they must be carefully monitored.

14. A. These clients have severely depleted levels of sodium and potassium because of their starvation diet and energy expenditure, these electrolytes are necessary for cardiac functioning.

15. B. Limiting unnecessary interaction will decrease stimulation and agitation.

16. C. Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

17. D. The nurse needs to set limits in the client’s manipulative behavior to help the client control dysfunctional behavior. A consistent approach by the staff is necessary to decrease manipulation.

18. B. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s statement with her to determine its meaning in terms of suicide.

19. A. When the staff member ask the client if he wonders why others find him repulsive, the client is likely to feel defensive because the question is belittling. The natural tendency is to counterattack the threat to self image.

20. B. The nurse would specifically use supportive confrontation with the client to point out discrepancies between what the client states and what actually exists to increase responsibility for self.

21. C. The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client’s experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

22. D. Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness.

23. D. Vomiting and diarrhea are usually the late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.

24. D. Moving to a client’s personal space increases the feeling of threat, which increases anxiety.

25. A. Environmental (MILIEU) therapy aims at having everything in the client’s surrounding area toward helping the client.

26. C. Children who have experienced attachment difficulties with primary caregiver are not able to trust others and therefore relate superficially

27. A. Children have difficulty verbally expressing their feelings, acting out behavior, such as temper tantrums, may indicate underlying depression.

28. D. The autistic child repeat sounds or words spoken by others.

29. D. The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.

30. A. Discussion of the feared object triggers an emotional response to the object.

31. B. The nurse presence may provide the client with support & feeling of control.

32. D. Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post traumatic stress disorder from other anxiety disorder.

33. C. Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.

34. A. These are the major signs of anorexia nervosa. Weight loss is excessive (15% of expected weight).

35. C. Dental enamel erosion occurs from repeated self-induced vomiting.

36. B. Depression usually is both emotional & physical. A simple daily routine is the best, least stressful and least anxiety producing.

37. D. The expression of these feeling may indicate that this client is unable to continue the struggle of life.

38. A. Structure tends to decrease agitation and anxiety and to increase the client’s feeling of security.

39. B. The rituals used by a client with obsessive compulsive disorder help control the anxiety level by maintaining a set pattern of action.

40. C. A person with this disorder would not have adequate self-boundaries.

41. D. Loose associations are thoughts that are presented without the logical connections usually necessary for the listening to interpret the message.

42. C. Helping the client to develop feeling of self worth would reduce the client’s need to use pathologic defenses.

43. B. Open ended questions and silence are strategies used to encourage clients to discuss their problem in descriptive manner.

44. C. Clients who are withdrawn may be immobile and mute, and require consistent, repeated interventions. Communication with withdrawn clients requires much patience from the nurse. The nurse facilitates communication with the client by sitting in silence, asking open-ended question and pausing to provide opportunities for the client to respond.

45. D. When hallucination is present, the nurse should reinforce reality with the client.

46. A. Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.

47. D. A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.

48. C. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.

49. D. Electroconvulsive therapy is an effective treatment for depression that has not responded to medication.

50. B. In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of outmost important in treating this potentially life threatening situation.

PART 2

1. Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:

a. Termination phase when discharge plans are being made.b. Working phase when the client shows some progress.c. Orientation phase when a contract is established.d. Working phase when the client brings it up.

2. Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic?

a. Question the client until he respondsb. Initiate contact with the client frequentlyc. Sit outside the clients roomd. Wait for the client to begin the conversation

3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene.Which of the following nursing actions would be most appropriate?

a. Waiting until the client’s family can participate in the client’s careb. Asking the client if he is ready to take showerc. Explaining the importance of hygiene to the clientd. Stating to the client that it’s time for him to take a shower

4. When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include?

a. Roasted chickenb. Fresh fishc. Salamid. Hamburger

5. When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects?

a. Urine retention and blurred visionb. Respiratory depression and convulsionc. Delirium and Sedationd. Tremors and cardiac arrhythmias

6. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?

a. ECT

b. Psychotherapeutic approachc. Psychoanalysisd. Antidepressant therapy

7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, “Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?

a. Echolaliab. Neologismc. Clang associationsd. Flight of ideas

8. Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry’s plan of care?

a. Watching TVb. Cleaning dayroom tablesc. Leading group activityd. Reading a book

9. When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?

a. Wrist cuttingb. Head bangingc. Use of gund. Aspirin overdose

10. Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?

a. “I’m of no use to anyone anymore.”b. “I know my kids don’t need me anymore since they’re grown.”c. “I couldn’t kill myself because I don’t want to go to hell.”d. “I don’t think about killing myself as much as I used to.”

11. Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur?

a. Using exercise bicycleb. Meditatingc. Watching TVd. Reading comics

12. When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet

anticipate administering if the client developed extra pyramidal side effects?

a. Olanzapine (Zyprexa)b. Paroxetine (Paxil)c. Benztropine mesylate (Cogentin)d. Lorazepam (Ativan)

13. Jon a suspicious client states that “I know you nurses are spraying my food with poison as you take it out of the cart.” Which of the following would be the best response of the nurse?

a. Giving the client canned supplements until the delusion subsidesb. Asking what kind of poison the client suspects is being usedc. Serving foods that come in sealed packagesd. Allowing the client to be the first to open the cart and get a tray

14. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective?

a. The client responds to verbal directions to eatb. The client initiates simple activities without directionc. The client walks with the nurse to her roomd. The client is able to move all extremities occasionally

15. Nurse Hazel invites new client’s parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues?

a. Developing a support network with other familiesb. Feeling more guilty about the client’s illnessc. Recognizing the client’s weaknessd. Managing their financial concern and problems

16. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others?

a. Attending an activity with the nurseb. Leading a sing a long in the afternoonc. Participating solely in group activitiesd. Being involved with primarily one to one activities

17. Which statement about an individual with a personality disorder is true?

a. Psychotic behavior is common during acute episodesb. Prognosis for recovery is good with therapeutic intervention

c. The individual typically remains in the mainstream of society, although he has problems in social and occupational rolesd. The individual usually seeks treatment willingly for symptoms that are personally distressful.

18. Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas?

a. Discussing his relationship with his motherb. Asking him to explain reasons for his seductive behaviorc. Suggesting to apologize to others for his behaviord. Explaining the negative reactions of others toward his behavior

19. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend which of the following activities for Tina?

a. Baking classb. Role playingc. Scrap book makingd. Music group

20. Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client’s possession will the nurse most likely place in a locked area?

a. Toothpasteb. Shampooc. Antiseptic washd. Moisturizer

21. Which of the following assessment would provide the best information about the client’s physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?a. Sleeping patternb. Mental alertnessc. Nutritional statusd. Vital signs

22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following?

a. Respiratory depressionb. Epilepsyc. Kidney failured. Cerebral edema

23. Which of the following would nurse Ronald use as the best measure to determine a client’s progress in rehabilitation?

a. The way he gets along with his parentsb. The number of drug-free days he hasc. The kinds of friends he makesd. The amount of responsibility his job entails

24. A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following?

a. Epilepsyb. Myocardial Infarctionc. Renal failured. Respiratory failure

25. Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following?

a. Delusionb. Formicationc. Flash backd. Confusion

26. Jose is diagnosed with amphetamine psychosis and was admitted in the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication?

a. Libriumb. Valiumc. Ativand. Haldol

27. Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?

a. Shakeb. Teac. Cranberry Juiced. Grape juice

28. When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate?

a. Facilitating progressive review of the accident and its consequencesb. Postponing discussion of the accident until the client brings it upc. Telling the client to avoid details of the accidentd. Helping the client to evaluate her sister’s behavior

29. The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?

a. Tell the client he’ll need to wait until supper to eat if he misses lunchb. Invite the client to lunch and accompany him to the dining roomc. Inform the client that he has 10 minutes to get to the dining room for lunchd. Take the client a lunch tray and let the client eat in his room

30. The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:

a. Presenting full reality of the loss of the individualsb. Directing the individual’s activities at this timec. Staying with the individuals involvedd. Mobilizing the individual’s support system

31. Joy’s stream of consciousness is occupied exclusively with thoughts of her father’s death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as:

a. Shock and disbeliefb. Developing awarenessc. Resolving the lossd. Restitution

32. When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of:

a. Accentuated premorbid traitsb. Enhance intelligencec. Increased inhibitionsd. Hyper vigilance

33. What is the priority care for a client with a dementia resulting from AIDS?

a. Planning for remotivational therapyb. Arranging for long term custodial carec. Providing basic intellectual stimulationd. Assessing pain frequently

34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey would expect an adolescent client with anorexia to exhibit:

a. Affective instabilityb. Dishered, unkempt physical appearancec. Depersonalization and derealizationd. Repetitive motor mechanisms

35. The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be:

a. Situational low self-esteem related to altered roleb. Powerlessness related to the loss of idealized selfc. Spiritual distress related to depressiond. Impaired verbal communication related to depression

36. When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to?

a. Isolate his gym timeb. Encourage his active participation in unit programsc. Provide foods, fluids and restd. Encourage his participation in programs

37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of:

a. Repressionb. Lonelinessc. Angerd. Paranoia

38. One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client “We’re doing the best we can. There are a lot of other people on the unit who needs attention too.” This statement shows that the nurse’s use of:

a. Defensive behaviorb. Reality reinforcementc. Limit-setting behaviord. Impulse control

39. A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be:

a. Verbalizing the need for anxiety medications

b. Recognizing each existing personalityc. Engaging in object-oriented activitiesd. Eliminating defense mechanisms and phobia

40. A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client’s fear of:

a. Phobiab. Powerlessnessc. Punishmentd. Rejection

41. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s difficulties began in:

a. Early childhoodb. Late childhoodc. Adolescenced. Puberty

42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example of:

a. Somatic delusionsb. Depersonalizationc. Hypochondriasisd. Echolalia

43. In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate:

a. Slumped posture, pessimistic out look and flight of ideasb. Grandiosity, arrogance and distractibilityc. Withdrawal, regressed behavior and lack of social skillsd. Disorientation, forgetfulness and anxiety

44. One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is:

a. Physically ill and experiencing abdominal discomfortb. Tired and probably did not sleep well last nightc. Attempting to hide from the nursed. Feeling more anxious today

45. Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should:

a. Invite the client to help decorate the dayroomb. Leave the client alone until he stops talkingc. Ask the client why he is smiling and talkingd. Tell the client it is not good for him to talk to himself

46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly:

a. While watching TVb. During meal timec. During group activitiesd. After going to bed

47. Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:

a. Projectionb. Identificationc. Repressiond. Regression

48. When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of:

a. Giving the client difficult tasks to provide stimulationb. Providing the client with activities in which success can be achievedc. Removing stress so that the client can relaxd. Not placing any demands on the client

49. Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is:

a. Displacementb. Denialc. Projectiond. Compensation

50. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of:

a. Disorientation, paranoia, tachycardiab. Tremors, fever, profuse diaphoresisc. Irritability, heightened alertness, jerky movementsd. Yawning, anxiety, convulsions

PART 2 ANSWERS

1. C . When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.

2. B . The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client’s self-esteem.

3. D . The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, “It’s time for a shower”, and assists the client with personal hygiene to preserve his dignity and self-esteem.

4. C . Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.

5. A . Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.

6. B . Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image, negative feelings about the future.

7. D . Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.

8. B . The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.

9. C . A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.

10. D . The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.

11. A . Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.

12. C . The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.

13. D . Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.

14. B . Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.

15. A . Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.

16. C . Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.

17. C . An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people’s reaction to the individual’s behavior.

18. D . The nurse would explain the negative reactions of others towards the client’s behaviors to make the clients aware of the impact of his seductive behaviors on others.

19. B . The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately.

20. C . Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.

21. D . Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.

22. A . After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.

23. B . The best measure to determine a client’s progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is.

24. D . Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.

25. B . The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.

26. D . The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.

27. C . An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.28. A . The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.

29. B . The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth.

30. C . This provides support until the individuals coping mechanisms and personal support systems can be immobilized.

31. C . Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.

32. A . A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.

33. C . This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.

34. A . Individuals with anorexia often display irritability, hospitality, and a depressed mood.

35. D . Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.

36. C . The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.

37. B . The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.

38. A . The nurse’s response is not therapeutic because it does not recognize the client’s needs but tries to make the client feel guilty for being demanding.

39. B . The client must recognize the existence of the sub personalities so that interpretation can occur.

40. D . An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.

41. C . The usual age of onset of schizophrenia is adolescence or early childhood.

42. A . Somatic delusion is a fixed false belief about one’s body.

43. C . These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.

44. D . The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.

45. B . This provides a stimulus that competes with and reduces hallucination.

46. D . Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.

47. A . Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.

48. B . This will help the client develop self-esteem and reduce the use of paranoid ideation.

49. B . Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.

50. C . Alcohol is a central nervous system depressant. These symptoms are the body’s neurologic adaptation to the withdrawal of alcohol.

PART 3

1. Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should expect to observe:

a. Hyperactivityb. Depressionc. Suspiciond. Delirium

2. Nurse John is aware that a serious effect of inhaling cocaine is?

a. Deterioration of nasal septumb. Acute fluid and electrolyte imbalancesc. Extra pyramidal tract symptomsd. Esophageal varices

3. A tentative diagnosis of opiate addiction, Nurse Candy should assess a recently hospitalized client for signs of opiate withdrawal. These signs would include:

a. Rhinorrhea, convulsions, subnormal temperatureb. Nausea, dilated pupils, constipationc. Lacrimation, vomiting, drowsinessd. Muscle aches, papillary constriction, yawning

4. A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client’s wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:

a. A past history of depressionb. Current plans to commit suicidec. The presence of marital difficultiesd. Feelings of excessive failure

5. Before helping a male client who has been sexually assaulted, nurse Maureen should recognize that the rapist is motivated by feelings of:

a. Hostilityb. Inadequacyc. Incompetenced. Passion

6. When working with children who have been sexually abused by a family member it is important for the nurse to understand that these victims usually are overwhelmed with feelings of:

a. Humiliationb. Confusionc. Self blamed. Hatred

7. Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the “rotten nursing care”. When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of:

a. Projectionb. Displacementc. Deniald. Reaction formation

8. The most critical factor for nurse Linda to determine during crisis intervention would be the client’s:

a. Available situational supportsb. Willingness to restructure the personalityc. Developmental theoryd. Underlying unconscious conflict

9. Nurse Trish suggests a crisis intervention group to a client experiencing a developmental crisis. These groups are successful because the:

a. Crisis intervention worker is a psychologist and understands behavior patternsb. Crisis group supplies a workable solution to the client’s problemc. Client is encouraged to talk about personal problemsd. Client is assisted to investigate alternative approaches to solving the identified problem

10. Nurse Ronald could evaluate that the staff’s approach to setting limits for a demanding, angry client was effective if the client:

a. Apologizes for disrupting the unit’s routine when something is neededb. Understands the reason why frequent calls to the staff were madec. Discuss concerns regarding the emotional condition that required hospitalizationsd. No longer calls the nursing staff for assistance

11. Nurse John is aware that the therapy that has the highest success rate for people with phobias would be:

a. Psychotherapy aimed at rearranging maladaptive thought processb. Psychoanalytical exploration of repressed conflicts of an earlier development phasec. Systematic desensitization using relaxation techniqued. Insight therapy to determine the origin of the anxiety and fear

12. When nurse Hazel considers a client’s placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client’s:

a. Perceptual fieldb. Delusional systemc. Memory stated. Creativity level

13. In the diagnosis of a possible pervasive developmental autistic disorder. The nurse would find it most unusual for a 3 year old child to demonstrate:a. An interest in musicb. An attachment to odd objectsc. Ritualistic behaviord. Responsiveness to the parents

14. Malou with schizophrenia tells Nurse Melinda, “My intestines are rotted from worms chewing on them.” This statement indicates a:

a. Jealous delusionb. Somatic delusionc. Delusion of grandeurd. Delusion of persecution

15. Andy is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. Nurse Hilary should expects the assessment to reveal:

a. Coldness, detachment and lack of tender feelingsb. Somatic symptomsc. Inability to function as responsible parentd. Unpredictable behavior and intense interpersonal relationships

16. PROPRANOLOL (Inderal) is used in the mental health setting to manage which of the following conditions?

a. Antipsychotic – induced akathisia and anxietyb. Obsessive – compulsive disorder (OCD) to reduce ritualistic behaviorc. Delusions for clients suffering from schizophreniad. The manic phase of bipolar illness as a mood stabilizer

17. Which medication can control the extra pyramidal effects associated with antipsychotic agents?

a. Clorazepate (Tranxene)b. Amantadine (Symmetrel)c. Doxepin (Sinequan)d. Perphenazine (Trilafon)

18. Which of the following statements should be included when teaching clients about monoamine oxidase inhibitor (MAOI) antidepressants?

a. Don’t take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)b. Have blood levels screened weekly for leucopeniac. Avoid strenuous activity because of the cardiac effects of the drugd. Don’t take prescribed or over the counter medications without consulting the physician

19. Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience:

a. Heightened concentrationb. Decreased perceptual fieldc. Decreased cardiac rated. Decreased respiratory rate

20. Initial interventions for Marco with acute anxiety include all except which of the following?

a. Touching the client in an attempt to comfort himb. Approaching the client in calm, confident mannerc. Encouraging the client to verbalize feelings and concernsd. Providing the client with a safe, quiet and private place

21. Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:

a. Uticariab. Vertigoc. Sedationd. Diarrhea

22. When performing a physical examination on a female anxious client, nurse Nelli would expect to find which of the following effects produced by the parasympathetic system?

a. Muscle tensionb. Hyperactive bowel soundsc. Decreased urine outputd. Constipation

23. Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)?

a. Divalproex (depakote) and Lithium (lithobid)b. Chlordiazepoxide (Librium) and diazepam (valium)c. Fluvoxamine (Luvox) and clomipramine (anafranil)d. Benztropine (Cogentin) and diphenhydramine (benadryl)

24. Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include:

a. Severe anxiety and fearb. Withdrawal and failure to distinguish reality from fantasyc. Depression and weight lossd. Insomnia and inability to concentrate

25. Which nursing action is most appropriate when trying to diffuse a client’s impending violent behavior?

a. Place the client in seclusionb. Leaving the client alone until he can talk about his feelingsc. Involving the client in a quiet activity to divert attentiond. Helping the client identify and express feelings of anxiety and anger

26. Rosana is in the second stage of Alzheimer’s disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain?

a. “Where is your pain located?”b. “Do you hurt? (pause) “Do you hurt?”c. “Can you describe your pain?”d. “Where do you hurt?”

27. Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for:

a. General anesthesiab. Cardiac stress testingc. Neurologic examinationd. Physical therapy

28. Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine, a compound found in which of the following foods?

a. Figs and cream cheeseb. Fruits and yellow vegetablesc. Aged cheese and Chianti wined. Green leafy vegetables

29. Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find:

a. Permanent short-term memory loss and hypertensionb. Permanent long-term memory loss and hypomaniac. Transitory short-term memory loss and permanent long-term memory lossd. Transitory short and long term memory loss and confusion

30. Barbara with bipolar disorder is being treated with lithium for the first time. Nurse Clint should observe the client for which common adverse effect of lithium?

a. Polyuriab. Seizuresc. Constipationd. Sexual dysfunction

31. Nurse Fred is assessing a client who has just been admitted to the ER department. Which signs would suggest an overdose of an antianxiety agent?

a. Suspiciousness, dilated pupils and incomplete BPb. Agitation, hyperactivity and grandiose ideationc. Combativeness, sweating and confusiond. Emotional lability, euphoria and impaired memory

32. Discharge instructions for a male client receiving tricyclic antidepressants include which of the following information?

a. Restrict fluids and sodium intakeb. Don’t consume alcoholc. Discontinue if dry mouth and blurred vision occurd. Restrict fluid and sodium intake

33. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?

a. Increased incidence of dysmenorrhea while taking the drugb. Occurrence of incomplete libido due to medication adverse effectsc. Continuing previous use of contraception during periods of amenorrhead. Instruction that amenorrhea is irreversible

34. A client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. Which information should the community health nurse assess first during the initial follow-up with this client?

a. Income level and living arrangementsb. Involvement of family and support systemsc. Reason for inpatient admissiond. Reason for refusal to take medications

35. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change?

a. Decreased dopamine levelb. Increased acetylcholine levelc. Stabilization of serotonind. Stimulation of GABA

36. Which of the following best explains why tricyclic antidepressants are used with caution in elderly patients?

a. Central Nervous System effectsb. Cardiovascular system effectsc. Gastrointestinal system effectsd. Serotonin syndrome effects

37. A client with depressive symptoms is given prescribed medications and talks with his therapist about his belief that he is worthless and unable to cope with life. Psychiatric care in this treatment plan is based on which framework?

a. Behavioral frameworkb. Cognitive frameworkc. Interpersonal frameworkd. Psychodynamic framework

38. A nurse who explains that a client’s psychotic behavior is unconsciously motivated understands that the client’s disordered behavior arises from which of the following?

a. Abnormal thinkingb. Altered neurotransmittersc. Internal needsd. Response to stimuli

39. A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client’s employer expects the client to return to work following inpatient treatment. The client tells the nurse, “I’m no good. I’m a failure”. According to cognitive theory, these statements reflect:

a. Learned behaviorb. Punitive superego and decreased self-esteemc. Faulty thought processes that govern behaviord. Evidence of difficult relationships in the work environment

40. The nurse describes a client as anxious. Which of the following statement about anxiety is true?

a. Anxiety is usually pathologicalb. Anxiety is directly observablec. Anxiety is usually harmfuld. Anxiety is a response to a threat

41. A client with a phobic disorder is treated by systematic desensitization. The nurse understands that this approach will do which of the following?

a. Help the client execute actions that are fearedb. Help the client develop insight into irrational fearsc. Help the client substitutes one fear for anotherd. Help the client decrease anxiety

42. Which client outcome would best indicate successful treatment for a client with an antisocial personality disorder?

a. The client exhibits charming behavior when around authority figuresb. The client has decreased episodes of impulsive behaviorsc. The client makes statements of self-satisfactiond. The client’s statements indicate no remorse for behaviors

43. The nurse is caring for a client with an autoimmune disorder at a medical clinic, where alternative medicine is used as an adjunct to traditional therapies. Which information should the nurse teach the client to help foster a sense of control over his symptoms?

a. Pathophysiology of disease processb. Principles of good nutritionc. Side effects of medicationsd. Stress management techniques

44. Which of the following is the most distinguishing feature of a client with an antisocial personality disorder?

a. Attention to detail and orderb. Bizarre mannerisms and thoughtsc. Submissive and dependent behaviord. Disregard for social and legal norms

45. Which nursing diagnosis is most appropriate for a client with anorexia nervosa who expresses feelings of guilt about not meeting family expectations?

a. Anxietyb. Disturbed body image

c. Defensive copingd. Powerlessness

46. A nurse is evaluating therapy with the family of a client with anorexia nervosa. Which of the following would indicate that the therapy was successful?

a. The parents reinforced increased decision making by the clientb. The parents clearly verbalize their expectations for the clientc. The client verbalizes that family meals are now enjoyabled. The client tells her parents about feelings of low-self esteem

47. A client with dysthymic disorder reports to a nurse that his life is hopeless and will never improve in the future. How can the nurse best respond using a cognitive approach?

a. Agree with the client’s painful feelingsb. Challenge the accuracy of the client’s beliefc. Deny that the situation is hopelessd. Present a cheerful attitude

48. A client with major depression has not verbalized problem areas to staff or peers since admission to a psychiatric unit. Which activity should the nurse recommend to help this client express himself?

a. Art therapy in a small groupb. Basketball game with peers on the unitc. Reading a self-help book on depressiond. Watching movie with the peer group

49. The home health psychiatric nurse visits a client with chronic schizophrenia who was recently discharged after a prolong stay in a state hospital. The client lives in a boarding home, reports no family involvement, and has little social interaction. The nurse plan to refer the client to a day treatment program in order to help him with:

a. Managing his hallucinationsb. Medication teachingc. Social skills trainingd. Vocational training

50. Which activity would be most appropriate for a severely withdrawn client?

a. Art activity with a staff memberb. Board game with a small group of clientsc. Team sport in the gymd. Watching TV in the dayroom

PART 3 ANSWERS

1. B. There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug. 

2. A. Cocaine is a chemical that when inhaled, causes destruction of the mucous membranes of the nose. 

3. D. These adaptations are associated with opiate withdrawal which occurs after cessation or reduction of prolonged moderate or heavy use of opiates. 

4. B. Whether there is a suicide plan is a criterion when assessing the client’s determination to make another attempt. 

5. A. Rapists are believed to harbor and act out hostile feelings toward all women through the act of rape. 

6. C. These children often have nonsexual needs met by individual and are powerless to refuse.Ambivalence results in self-blame and also guilt. 

7. B. The client’s anger over the abortion is shifted to the staff and the hospital because she is unable to deal with the abortion at this time. 

8. A. Personal internal strength and supportive individuals are critical factors that can be employed to assist the individual to cope with a crisis. 

9. D. Crisis intervention group helps client reestablish psychologic equilibrium by assisting them to explore new alternatives for coping. It considers realistic situations using rational and flexible problem solving methods. 

10. C. This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior. 

11. C. The most successful therapy for people with phobias involves behavior modification techniques using desensitization. 

12. A. Perceptual field is a key indicator of anxiety level because the perceptual fields narrow as anxiety increases. 

13. D. One of the symptoms of autistic child displays a lack of responsiveness to others. There is little or no extension to the external environment. 

14. B. Somatic delusions focus on bodily functions or systems and commonly include delusion about foul odor emissions, insect manifestations, internal 

parasites and misshapen parts. 

15. D. A client with borderline personality displays a pervasive pattern of unpredictable behavior, mood and self image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive. 

16. A. Propranolol is a potent beta adrenergic blocker and producing a sedating effect, therefore it is used to treat antipsychotic induced akathisia and anxiety. 

17. B. Amantadine is an anticholinergic drug used to relive drug-induced extra pyramidal adverse effects such as muscle weakness, involuntary muscle movements, pseudoparkinsonism and tar dive dyskinesia. 

18. D. MAOI antidepressants when combined with a number of drugs can cause life-threatening hypertensive crisis. It’s imperative that a client checks with his physician and pharmacist before taking any other medications. 

19. B. Panic is the most severe level of anxiety. During panic attack, the client experiences a decrease in the perceptual field, becoming more focused on self, less aware of surroundings and unable to process information from the environment. The decreased perceptual field contributes to impaired attention andinability to concentrate. 

20. A. The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety. 

21. D. Diarrhea is a common physiological response to stress and anxiety. 

22. B. The parasympathetic nervous system would produce incomplete G.I. motility resulting in hyperactive bowel sounds, possibly leading to diarrhea. 

23. C. The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD. 

24. A. Phobias cause severe anxiety (such as panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia and elevated B.P. 

25. D. In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statement as “What happened to get you this angry?” may help the client verbalizes feelings rather than act on them. 

26. B. When speaking to a client with Alzheimer’s disease, the nurse should use close-ended questions.Those that the client can answer with “yes” or “no” whenever possible and avoid questions that require the client to make choices. Repeating the question aids comprehension. 

27. A. The nurse should prepare a client for ECT in a manner similar to that for general anesthesia. 

28. C. Aged cheese and Chianti wine contain high concentrations of tyramine. 

29. D. ECT commonly causes transitory short and long term memory loss and confusion, especially in geriatric clients. It rarely results in permanent short and long term memory loss. 

30. A. Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit. 

31. D. Signs of anxiety agent overdose include emotional lability, euphoria and impaired memory. 

32. B. Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. 

33. C. Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn’t indicate cessation of ovulation thus, the client can still be pregnant. 

34. D. The first are for assessment would be the client’s reason for refusing medication. The client may not understand the purpose for the medication, may be experiencing distressing side effects, or may be concerned about the cost of medicine. In any case, the nurse cannot provide appropriate intervention before assessing the client’s problem with the medication. The patient’s income level, living arrangements, and involvement of family and support systems are relevant issues following determination of the client’s reason for refusing medication. The nurse providing follow-up care would have access to the client’s medical record and should already know the reason for inpatient admission. 

35. A. Excess dopamine is thought to be the chemical cause for psychotic thinking. The typical antipsychotics act to block dopamine receptors and therefore decrease the amount of neurotransmitter at the synapses. The typical antipsychotics do not increase acetylcholine, stabilize serotonin, stimulate GABA. 

36. B. The TCAs affect norepinephrine as well as other neurotransmitters, and thus have significant cardiovascular side effects. Therefore, they are used with caution in elderly clients who may have increased risk factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any client taking a TCA and are not particular to an elderly person. 

37. B. Cognitive thinking therapy focuses on the client’s misperceptions about self, others and the world that impact functioning and contribute to symptoms. Using medications to alter neurotransmitter activity is a psychobiologic approachto treatment. The other answer choices are frameworks for care, but hey are not applicable to this situation. 

38. C. The concept that behavior is motivated and has meaning comes from the psychodynamic framework. According to this perspective, behavior arises from internal wishes or needs. Much of what motivates behavior comes from the unconscious. The remaining responses do not address the internal forces thought to motivate behavior. 

39. C. The client is demonstrating faulty thought processes that are negative and that govern his behavior in his work situation – issues that are typically examined using a cognitive theory approach. Issues involving learned behavior are best explored through behavior theory, not cognitive theory. Issues involving ego development are the focus of psychoanalytic theory. Option 4 is incorrect because there is no evidence in this situation that the client has conflictual relationships in the work environment. 

40. D. Anxiety is a response to a threat arising from internal or external stimuli. 

41. A. Systematic desensitization is a behavioral therapy technique that helps clients with irrational fears and avoidance behavior to face the thing they fear, without experiencing anxiety. There is no attempt to promote insight with this procedure, and the client will not be taught to substitute one fear for another. Although the client’s anxiety may decrease with successful confrontation of irrational fears, the purpose of the procedure is specifically related to performing activities that typically are avoided as part of the phobic response. 

42. B. A client with antisocial personality disorder typically has frequent episodes of acting impulsively with poor ability to delay self-gratification. Therefore, decreased frequency of impulsive behaviors would be evidence of improvement. Charming behavior when around authority figures and statements indicating no remorse are examples of symptoms typical of someone with this disorder and would not indicate successful treatment. Self-satisfaction would be viewed as a positive change if the client expresses low self-esteem; however this is not a characteristic of a client with antisocial personality disorder. 

43. D. In autoimmune disorders, stress and the response to stress can exacerbate symptoms. Stress management techniques can help the client reduce the psychological response to stress, which in turn will help reduce the physiologic stress response. This will afford the client an increased sense of control over his symptoms. The nurse can address the remaining answer choices in her teaching about the client’s disease and treatment; however, knowledge alone will not help the client to manage his stress effectively enough to control symptoms. 

44. D. Disregard for established rules of society is the most common characteristic of a client with antisocial personality disorder. Attention to detail and order is characteristic of someone with obsessive compulsive disorder. Bizarre mannerisms and thoughts are characteristics of a client with schizoid or schizotypal disorder. Submissive and dependent behaviors are characteristic of someone with a dependent personality. 

45. D. The client with anorexia typically feels powerless, with a sense of having little control over any aspect of life besides eating behavior. Often, parental expectations and standards are quite high and lead to the clients’ sense of guilt over not measuring up. 

46. A. One of the core issues concerning the family of a client with anorexia is control. The family’s acceptance of the client’s ability to make independent decisions is key to successful family intervention. Although the remaining options may occur during the process of therapy, they would not necessarily indicate a successful outcome; the central family issues of dependence and independence are not addresses on these responses. 

47. B. Use of cognitive techniques allows the nurse to help the client recognize that this negative beliefs may be distortions and that, by changing his thinking, he can adopt more positive beliefs that are realistic and hopeful. Agreeing with the client’s feelings and presenting

a cheerful attitude are not consistent with a cognitive approach and would not be helpful in this situation. Denying the client’s feelings is belittling and may convey that the nurse does not understand the depth of the client’s distress. 

48. A. Art therapy provides a nonthreatening vehicle for the expression of feelings, and use of a small group will help the client become comfortable with peers in a group setting. Basketball is a competitive game that requires energy; the client with major depression is not likely to participate in this activity. Recommending that the client read a self-help book may increase, not decrease his isolation. Watching movie with a peer group does not guarantee that interaction will occur; therefore, the client may remain isolated. 

49. C. Day treatment programs provide clients with chronic, persistent mental illness training in social skills, such as meeting and greeting people, asking questions or directions, placing an order in a restaurant, taking turns in a group setting activity. Although management of hallucinations and medication teaching may also be part of the program offered in a day treatment, the nurse is referring the client in this situation because of his need for socialization skills. Vocational training generally takes place in a rehabilitation facility; the client described in this situation would not be a candidate for this service. 

50. A. The best approach with a withdrawn client is to initiate brief, nondemanding activities on a one-to-one basis. This approach gives the nurse an opportunity to establish a trusting relationship with the client. A board game with a group clients or playing a team sport in the gym may overwhelm a severely withdrawn client. Watching TV is a solitary activity that will reinforce the client’s withdrawal from others. 

PART 4

1. 60 year old post CVA patient is taking TPA for his disease, the nurse understands that this is an example of what level of prevention? 

a. primary  b. secondary  c. tertiary  d. nota  2. A female client undergoes yearly mammography. This is a type of what level of prevention? a. primary  b. secondary  c. tertiary  d. nota  

3. A Diabetic patient was amputated following an unexpected necrosis on the right leg, he sustained and undergone BKA. He then underwent therapy on how to use his new prosthetic leg. This is a type of what level of prevention? 

a. primary  b. secondary  c. tertiary  d. nota 

4. As a care provider, The nurse should do first: 

a. Provide direct nursing care. b. Participate with the team in performing nursing intervention. c. Therapeutic use of self. d. Early recognition of the client’s needs. 

5. As a manager, the nurse should: 

a. Initiates nursing action with co workers. b. Plans nursing care with the patient. c. Speaks in behalf of the patient. d. Works together with the team.  6. The nurse shows a patient advocate role when 

a. defend the patients right b. refer patient for other services she needs c. work with significant others d. intercedes in behalf of the patient.   7. Which is the following is the most appropriate during the orientation phase? 

a. patients perception on the reason of her hospitalization b. identification of more effective ways of coping c. exploration of inadequate coping skills d. establishment of regular meeting of schedules  8. Preparing the client for the termination phase begins:  

a. pre orientation b. orientation  c. working  d. termination  9. A helping relationship is a process characterized by:  

a. recovery promoting  b. mutual interaction 

c. growth facilitating  d. health enhancing  10. During the nurse patient interaction, the nurse assesses the ff: to determine the patients coping strategy:  

a. how are you feeling right now? b. do you have anyone to take you home? c. what do you think will help you right now? d. How does your problem affect your life? 

 11. As a counselor, the nurse performs which of the ff: task? 

a. encourage client to express feelings and concerns b. helps client to learn a dance or song to enable her to participate in activities c. help the client prepare in group activities d. assist the client in setting limits on her behavior 

 12. Freud stresses out that the EGO 

a. Distinguishes between things in the mind and things in the reality. b. Moral arm of the personality that strives for perfection than pleasure. c. Reservoir of instincts and drives d. Control the physical needs instincts. 

 13. A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention? 

a. tell the friends to visit the child b. encourage patient to help child learn lessons missed c. call the priest to intervene d. tell the child’s girlfriend to visit the child. 

 14. NMS is characterized by : 

a. hypertension, hyperthermia, flushed and dry skin. b. Hypotension, hypothermia, flushed and dry skin. c. Hypertension, hyperthermia, diaphoresis d. Hypertension, hypothermia, diaphoresis   15. Which of the following drugs needs a WBC level checked regularl? 

a. Lithane b. Clozaril c. Tofranil d. Diazepam  16. Initially, The nurse identifies which of the ff: Nursing diagnosis: 

a. self centred disturbance  b. impaired social interaction c. sensory perceptual alteration  d. altered thought process  17. Which of the ff: is not a characteristic of PD? 

a. disregard rights of others b. loss of cognitive functioning c. fails to conform to social norms d. not capable of experiencing guild or remorse for their behaviour  18. The most effective treatment modality for persons if anti social PD is 

a. hypnotherapy b. gestalt therapy c. behavior therapy d. crisis intervention  19. Which of the following is not an example of alteration of perception? 

a. ideas of reference b. flight of ideas c. illusion d. hallucination  20. The type of anxiety that leads to personality disorganization is:  

a. Mild  b. moderate  c. severe  d. panic  21. A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors, hyperexicitability, tachycardia, diaphoresis and hypertension. The nurse suspects alcohol withdrawal. The nurse should ask the client: 

a. at what time was your last drink taken? b. Why didn’t you tell us you’re a drinker? c. Do you drink beer or hard liquor? d. How long have you been drinking? 

 22. Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurse's best response is: 

a. I understand that god’s voice are real to you, But I don’t hear anything. I will stay with you. 

b. The voices are part of your illness; it will stop if you take medication c. The voices are all in your imagination, think of something else and itll go away d. don’t think of anything right now, just go and relax. 

23. In assessing a client's suicide potential, which statement by the client would give the nurse the HIGHEST cause for concern? 

a. my thoughts of hurting myself are scary to me b. I’d like to go to sleep and not wake up c. I’ve thought about taking pills and alcohol till I pass out d. I’d like to be free from all these worries  24. A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect? 

a. Complains of dry mouth b. State he feels restless in his body c. Stops pacing and sits with the nurse d. Exhibits increase activity and speech 

 25. A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and unkempt was admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on: 

a. borderline personality disorder b. anxiety disorder c. schizophrenia d. depression  26. A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to: 

a. Hold a job. b. Relate to his peers. c. Perform activities of daily living. d. Behave in an outwardly normal   27. A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurse's highest priority in assessing the client on admission would be to ask him:  a. How he sleeps at night. b. If he is thinking about hurting himself. 

c. About recent stresses. d. How he feels about himself.  28. The nurse should know that the normal therapeutic level of lithium is

a. .6 to 1.2 meq/L b. 6 to 12 meq/L c. .6 to .12 cc/ml d. .6 to .12 cc3/L  29. The patient complaint of vomiting, diarrhea and restlessness after taking lithane. The nurse’s initial intervention is:  

a. recognize that this is a sign of toxicity and withhold the next medication. b. Notify the physician. c. Check V/S to validate patient’s concerns. d. Recognize that this is a normal side effects of lithium and still continue the drug.   30. The client is taking TOFRANIL. The nurse should closely monitor the patient for:  

a. Hypertension b. Hypothermia c. Increase Intra Ocular Pressure d. Increase Intra Cranial Pressure  31. A client was hospitalized with major depression with suicidal ideation for 1 week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges: 

a. The client to be decompensating and in need of being readmitted to the hospital. b. The client to need an adjustment or increase in his dose of antidepressant. c. The depression to be improving and the suicidal ideation to be lessening. d. The presence of suicidal ideation to warrant a telephone call to the client's physician   32. The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft? 

a. Zoloft causes erectile dysfunction in men. b. Zoloft causes postural hypotension 

c. Zoloft increases appetite and weight gain d. It may take 3-4 weeks before client will start feeling better.   33. After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of: 

a. Dystonia. b. Akathisia. c. Parkinsonism. d. Tardive dyskinesia.   34. After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following? 

a. A laboratory error. b. An anticipated therapeutic blood level of the drug. c. An atypical client response to the drug. d. A toxic level.  35. When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following? 

a. Hypertensive episodes. b. Extrapyramidal symptoms. c. Hypersalivation. d. Oversedation. 

36. A client is brought to the hospital’s emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms? 

a. Increased heart rate, dilated pupils, and fever. b. Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion. c. Decreased respirations, constricted pupils, and pallor. d. Eye irritation, tinnitus, and irritation of nasal and oral mucosa.  37. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse: 

a. Gives the medication as ordered. b. Questions the physician about the order. c. Questions the dosage ordered. d. Asks the physician to order benztropine (Cogentin) for the side effects. 

 38. Which of the following client statements about clozapine (Clozaril) indicates that the client needs additional teaching? 

a. "I need to have my blood checked once every several months while I’m taking this drug." b. "I need to sit on the side of the bed for a while when I wake up in the morning." c. "The sleepiness I feel will decrease as my body adjusts to clozapine." d. "I need to call my doctor whenever I notice that I have a fever or sore throat."  39. A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of: 

a. Sodium. b. Iron. c. Iodine. d. Calcium.  40. The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I'm not really better, and I've been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first? 

a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect. b. Tell the client to stop taking the medication and to call the physician. c. Encourage the client to double the dose of his medication. d. Ask the client if he has resumed smoking cigarettes.  41. The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates: 

a. An elevated blood glucose level. b. Insomnia. c. Hypertension. d. Urinary retention.  42. Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)? 

a. Electrocardiogram (ECG). b. Urine sample for protein. c. Thyroid scan. d. Creatinine clearance test. 

 43. A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? 

a."I need to call my doctor in 2 weeks for a checkup." b."I need to keep my appointment here at the hospital this week for a blood test." c. "I can drink alcohol with this medication." d. "I can take over-the-counter sleeping medication if I have trouble sleeping."  44. The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Which of the following negative symptoms will improve?. a. Abnormal thought form. b. Hallucinations and delusions. c. Bizarre behaviour. d. Asocial behaviour and anergia.   45. The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which food because of its high tyramine content? 

a. Nuts. b. Aged cheeses. c. Grain cereals. d. Reconstituted milk.  46. Which of the following clinical manifestations would alert the nurse to lithium toxicity? 

a. Increasingly agitated behaviour. b. Markedly increased food intake. c. Sudden increase in blood pressure. d.Anorexia with nausea and vomiting.  47. The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The physician orders a different drug, tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic antidepressant. Which of the following reactions should the client be cautioned about if her diet includes foods containing tryaminetyramine? 

a. Heart block. b. Grand mal seizure. c. Respiratory arrest. d. Hypertensive crisis.  48. After the nurse has taught the client who is being discharged on

lithium (Eskalith) about the drug, which of the following client statements would indicate that the teaching has been successful? 

a. "I need to restrict eating any foods that contain salt." b. "If I forget a dose, I can double the dose the next time I take it." c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness." d. "I should increase my fluid” 

 49. A nurse is caring for a client with Parkinson's disease who has been taking carbidopa/levodopa (Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the client for? 

a. dykinesia b. glaucoma c. hypotension d. respiratory depression  50. A client is taking fluoxetine hydrochloride (Prozac) for treatment of depression. The client asks the nurse when the maximum therapeutic response occurs. The nurse's best response is that the maximum therapeutic response for fluoxetine hydrochloride may occur in the: a. 10-14 days b. First week c. Third week d. Fourth week 

PART 4 ANSWERS

1. C. Tertiary : The client already had stroke, TPA stands for TRANSPLASMINOGEN ACTIVATOR which are thrombolytics, dissolving clots formed in the vessels of the brain. We are just preventing COMPLICATIONS here.  2. b. secondary : The client is never sick of anything but we are detecting the POSSIBILITY by giving yearly mammography. Remember that all kinds of tests, case findings and treatment belongs to the secondary level of prevention.  3. c. tertiary : Tertiary prevention involves rehabilitation. Client is now being assisted to perform ADLs at his optimum functioning. Remember that all kinds of rehabilitatory and palliative management is included in tertiary prevention.  4. d. Early recognition of the client’s needs. : we are talking about what should the nurse do first. ASSESSMENT involves early recognition of clients needs. A,B,C are all involve in the intervention phase of the nursing process. 

 5. d. Works together with the team. : As a nurse manager, you should be able to work with the team. A,B,C are not specific of a nurse manager. They can be done by an ordinary R.N.  6. a. defend the patients right : An advocate role is shown when the nurse defends the rights of the client. Interceding in behalf of the patient should not be done by a nurse. Counter transference can develop in that case and we should avoid that. Only the family and the health attorney of the patient can intercede or speak for the patient.  7. d. establishment of regular meeting of schedules : Orientation phase is synonymous with CONTRACT ESTABLISHMENT. Here, the nurse will establish regular meeting of schedule, agreements and giving the client information that there is a TERMINATION. Letter A and B assesses the client’s coping skills, which is in the working phase and so is letter B. In working phase, The nurse assesses the coping skills of the client and formulate plans and intervention to correct deficiencies. Although assessment is also made in the orientation phase, COPING SKILLS are assessed in the working phase.  8. c. working : Telling the client that there is a TERMINATION PHASE should be in the ORIENTATION PHASE, however, in preparing the client for the TERMINATION, it should be done in the working phase. The nurse will start to lessen the number of meetings to prevent development of transference or counter transference.  9. c. growth facilitating : In psychiatric nursing, The epitome of all nursing goal should focus on facilitating GROWTH of the client.  10. d. How does your problem affect your life? : this is the only question that determines the effects of the problem on the client and the ways she is dealing with it. Letter A can only be answered by FINE and close further communication. B is unrelated to coping strategies. Letter C, asking the client what do you think can help you right now is INAPPROPRIATE for the nurse to ask. The client is in the hospital because she needs help. If she knows something that can help her with her problem she shouldn’t be there.  11. a. encourage client to express feelings and concerns : A counselor is much more of a listener than a speaker. She encourage the client to express feelings and concerns as to formulate necessary response and facilitate a channel to express anger, disappointments and frustrations. 

 12. a. Distinguishes between things in the mind and things in the reality. : The ego is responsible for distinguishing what is REAL and what is NOT. It is the one that balances the ID and super ego. B and D is a characteristic of the SUPER EGO which is the CONTROLLER of instincts and drives and serve as our CONSCIENCE or the MORAL ARM. The ID is our DRIVES and INSTINCTS that is mediated by the EGO and controlled by the SUPER EGO.  13. a. tell the friends to visit the child : The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most significant persons in this group are the PEERS. B refers to children in the school age while C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying and the situation did not even talk about the child’s belief therefore, calling the priest is unnecessary.  14. c. Hypertension, hyperthermia, diaphoresis. : Neuroleptic malignant syndrome is a side effect of neuroleptics. This is characterized by fever, increase in blood pressure and warm, diaphoretic skin.  15. b. Clozaril : Clozapine is a dreaded aypical antipsychotic because it causes severe bone marrow depression, agranulocytosis, infection and sore throat. WBC count is important to assess if the clients immune function is severely impaired. The first presenting sign of agranulocytosis is SORE THROAT.   16. b. impaired social interaction : There is no such nursing diagnosis as A , looking at C and D, they are much more compatible to schizophrenia which is not a characteristic of an ANTI SOCIAL P.D which is shown in the situation. Remember that Personality Disorder is FAR from Psychoses. When client exhibits altered thought process or sensory alteration, It is not anymore a personality disorder but rather, a sign and symptom of psychoses.  17. b. loss of cognitive functioning : As I said, symptoms of PD will never show alteration in cognitive functioning. They are much more of SOCIAL Disturbances rather than PSYCHOLOGICAL.  18. c. behavior therapy : The problem of the patient is his behavior. A is done for patient who has insomnia or severe anxiety. B is a therapy that promotes growth by providing a contact, either a person or an environment who will facilitate the growth of an individual. It is a humanistic psychotherapeutic model approach. D is done on clients who are in crisis like trauma, post traumatic disorders, raped or accidents. 

 19.b. flight of ideas : Flight of ideas is a condition in which patient talks continuously and then switching to unrelated topic. An example is “ Ang ganda ng bulaklak na ito no budek? Rose ito hindi ba? Kilala mo ba si jack yung boyfriend ni rose? Grabe yung barko no ang laki laki tapos lumubog lang. Dapat sana nag seaman ako eh, gusto kasi ng nanay ko. “. Loose association is somewhat similar but the switch in topic is more obvious and completely unrelated. Example “ Ang cute nung rabbit, paano si paul kasi tanga eh, papapatay ko yan kay albert. Ang ganda nung bag na binigay ni jenny, tanga nga lang yung aswang dun sa kanto. Pero bakit ka ba andito? Wala akong pagkain, Penge ako kotse aakyat ako everest.”  A,C,D are all alteration in perception. A refers to a person thinking that everyone is talking about him. C and D are all sensory alterations. The difference is that, in hallucination, there is no need for a stimuli. In illusion, a stimuli [ A phone cord ] is mistakenly identified by the client as something else [ Snake ]  20. d. panic : Panic is the only level of anxiety that leads to personality disorganization.  21. a. at what time was your last drink taken? : This question will give the nurse idea WHEN will the withdrawal occur. Withdrawal occurs 5 to 10 hours after the last intake of alcohol. This is a crucial and mortality is very high during this period. Client will undergo delirium tremens, seizures and DEATH if not recognize earlier by the nurse. B is very judgmental, C is non specific, whether it is a beer or a wine It is still alcohol and has the same effects. D is a valuable question to determine the chronic effects of alcohol ingestion but asking letter A can broaden the line between life and death.  22. a. I understand that god’s voice are real to you, But I don’t hear anything. I will stay with you. : The nurse should first ACKNOWLEDGE that the voices are real to the patient and then, PRESENT REALITY by telling the patient that you do not hear anything. The third part of the nursing intervention in hallucination is LESSENING THE STIMULI by either staying with the patient or removing the patient from a highly stimulating place. Telling the client that the voices is part of his illness is not therapeutic. People with schizophrenia do not think that they are ILL. Letter C and D disregards the client’s concern and therefore, not therapeutic.  23. c. I’ve thought about taking pills and alcohol till I pass out : This is the only statement of the client that contains a specific and technical plan. B,D are all indicative of suicidal ideation but it contains no specific plans to carry out the objective. Letter A admits the client thinks of hurting himself, but not doing it because it scares him, therefore, it is not indicative of suicidal ideation.

24.c. Stops pacing and sits with the nurse : Thorazine is a neuroleptic. Desired effect evolve on controlling the client’s psychoses. Letter A is the side effect of the drug, which is not desired. B and D indicates that the drug is not effective in controlling the client’s agitation, restlessness and disorders of perception.  25. c. schizophrenia : When disorders of perception and thoughts came in, The only feasible diagnosis a doctor can make is among the choices is schizophrenia. A,B and D can occur in normal individuals without altering their perceptions. Schizophrenia is characterized by disorders of thoughts, hallucination, delusion, illusion and disorganization.  26. c. Perform activities of daily living : If a client can do ADLs , there is no reason for that client to be hospitalized.  27. b. If he is thinking about hurting himself :The client shows typical sign and symptoms of DEPRESSION. Moving slowly, gazes on the floor, blank stares and showing flat affect. The highest priority among depressed client is assessing any suicide plans or ideation for the nurse to establish a no suicide contract early on or, in any case client do not participate in a no suicide contract, a 24 hour continuous monitoring is established.  28. a. .6 to .12 meq/L : According to brunner and suddarths MS nursing, The normal therapeutic level of lithium is .6 to 1.2 meq/L. Some books will say .5 to 1.5 meq/L.  29. a. Recognize that this is a sign of toxicity and withhold the next medication. : The nurse should recognize that this is an early s/s of lithium toxicity. Taking the clients vital signs will not confirm diarrhea, vomiting or restlessness. Notifying the physician is unnecessary at this point and the physician will likely to withhold the medication.  30. c. Increase Intra Ocular Pressure : Tofranil is a neuroleptic. It is well known that this is the antipsychotic that increases the IOP and contraindicated in patients with glaucoma. Hypertension is not specific with TOFRANIL. All neuroleptics can cause NMS or the neuroleptic malignant syndrome.  31. c. The depression to be improving and the suicidal ideation to be lessening. : too obvious, no need to rationalize.  32. a. Zoloft causes erectile dysfunction in men : 

When you take zoloft, mag zozoloft ka nalang sa buhay. Because it causes erectile dysfuntion and decrease libido. Letter B and C are specific of TCAs. Zoloft will exert its effects as early as 1 week.  33. b. Akathisia : The client shows sign of motor restlessness, which is specific for Akathisia or MAKATI SYA.  34. b. An anticipated therapeutic blood level of the drug.  35. b. Extrapyramidal symptoms : Haldol is a neuroleptic, Specific to these neuroleptics are the EPS. The client will likely be hypotensive than hypertensive because neuroleptics causes postural hypotension, The client will complaint of dry mouth due to its anticholinergic properties. Dizziness and drowsiness are side effects of neuroleptics but not oversedation.  36.c. Decreased respirations, constricted pupils, and pallor. : Heroin is a narcotic. Together with morphine, meperidine, codeine and opiods, they are DEPRESSANTS and will cause decrease respiration, constricted pupils and pallor due to vasoconstriction.  37. b. Questions the physician about the order : 2 anti depressants cannot be given at the same time unless the other one is tapered while the other one is given gradually.  38. d. "I need to call my doctor whenever I notice that I have a fever or sore throat." : Clozapine causes AGRANULOCYTOSIS and bone marrow depression. Early s/s includes fever and sore throat. The medication is to be withheld this time or the patient might develop severe infection leading to death.   39. a. Sodium :The levels of lithium in the body are dependent on sodium. The higher the sodium, The lower the levels of lithium. Clients should have an adequate intake of sodium to prevent sudden increase in the levels of lithium leading to toxicity and death.  40. a. Tell the client to continue taking the medication as prescribed because it takes 5 to 10 weeks for a full therapeutic effect. : Anafranil is an anti depressant, effects are noticeable within 1 to 2 weeks.  41. d. Urinary retention : Elavil is an TC antidepressant. It should not cause insomnia. Hypertension are specific of MAOI anti depressants when tyramine is ingested. Due to the anticholinergic s/e of TCAs, Urinary retention is an

adverse effect.  42. a. Electrocardiogram (ECG). : Aside from tonometry or IOP measurement, Client should undergo regular ECG schedule. Most TCAs cause tachycardias and ECG changes, an ECG should be done before the client takes the medication.  43. b."I need to keep my appointment here at the hospital this week for a blood test." : Regular blood check up is required for patients taking clozaril. As frequent as every 2 weeks. Clozapine can cause bone marrow depression, therefore, frequent blood counts are necessary.  44. d. Asocial behaviour and anergia : A,B and C are all positive symptoms of schizophrenia. Negative symptoms includes anhedonia, anergia, associative looseness and Asocial behavior.  45. b. Aged cheeses. : This is high in tyramine, and therefore, removed from patients diet to prevent hypertensive crisis.  46. d.Anorexia with nausea and vomiting.  47.d. Hypertensive crisis.  48. c. "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness." : This is a sign of light lithium toxicity. Increasing fluid intake will cause dilutional decrease of lithium  level. Restriction of sodium will cause dilutional increase in lithium level.  49. c. hypotension : Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like levodopa and carbidopa.  50. c. Third week : A and B are similar, therefore , removed them first. Recognizing that most antidepressants exerts their effects within 2-3 weeks will lead you to letter C. 

PART 5

1. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as: 

 a. delusions.  b. hallucinations.  c. loose associations.  d. neologisms. 

 2. The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should: 

a. give him privacy in the bathroom. b. allow him to shave. c. open the window and allow him to get some fresh air. d. observe him. 

 3. The nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan? 

a. Restrict visits with the family until the client begins to eat. b. Provide privacy during meals. c. Set up a strict eating plan for the client. d. Encourage the client to exercise, which will reduce her anxiety. 

4. A client whose husband recently left her is admitted to the hospital with severe depression. The nurse suspects that the client is at risk for suicide. Which of the following questions would be most appropriate and helpful for the nurse to ask during an assessment for suicide risk? 

a. "Are you sure you want to kill yourself?" b. "I know if my husband left me, I'd want to kill myself. Is that what you think?" c. "How do you think you would kill yourself?" d. "Why don't you just look at the positives in your life?" 

 5. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates, such as morphine, include: 

a. dilated pupils and slurred speech. b. rapid speech and agitation. c. dilated pupils and agitation. d. euphoria and constricted pupils.  6. The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include: 

a. turning on the lights and opening the windows so that the client doesn't feel crowded. b. leaving the client alone. c. staying with the client and speaking in short sentences. d. turning on stereo music.  7.  The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for: 

a. a depressed client. b. a manic client. c. a suicidal client. d. an anxious client. 

 8. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is: 

a. highly important or famous. b. being persecuted. c. connected to events unrelated to oneself. d. responsible for the evil in the world.  9. The nurse is caring for a client, a Vietnam veteran, who exhibits signs and symptoms of posttraumatic stress disorder. Signs and symptoms of posttraumatic stress disorder include: 

a. hyper alertness and sleep disturbances. b. memory loss of traumatic event and somatic distress. c. feelings of hostility and violent behavior. d. sudden behavioral changes and anorexia.   10. The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include: 

a. offering high-calorie meals and strongly encouraging the client to finish all food. b. insisting that the client remain active throughout the day so that he'll sleep at night. c. allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. d. listening attentively with a neutral attitude and avoiding power struggles.  11.  A client is a Vietnam War veteran with a diagnosis of posttraumatic stress disorder. He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief of his symptoms? 

a. The opportunity to verbalize memories of trauma to a sympathetic listener b. Family support c. Prescribed medications taken as ordered d. Alcoholics Anonymous (AA) meetings 

12. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using? 

a. Withdrawal b. Logical thinking c. Repression d. Denial  13. A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping? 

a. Inability to make choices and decisions without advice b. Showing interest only in solitary activities c. Avoiding developing relationships d. Recurrent self-destructive behavior with history of depression  14. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is: 

a. impending coma. b. manipulating behavior. c. suppression. d. perceptual disorders. 

15. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations? 

a. Aggressive behavior b. Paranoid thoughts c. Emotional affect d. Independence needs  16. The nurse is caring for a client in an acute manic state. What's the most effective nursing action for this client? 

a. Assigning him to group activities b. Reducing his stimulation c. Assisting him with self-care d. Helping him express his feelings  17. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: 

a. avoid shopping for large amounts of food. b. control eating impulses. c. identify anxiety-causing situations. d. eat only three meals per day.  18. The nurse is caring for a 40-year-old client. Which behavior by the

client indicates adult cognitive development? 

a. Has perceptions based on reality b. Assumes responsibility for actions c. Generates new levels of awareness d. Has maximum ability to solve problems and learn new skills  19. A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium? 

a. Sexual dysfunction b. Constipation c. Polyuria d. Seizures  20. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: 

a. tension and irritability. b. slow pulse. c. hypotension. d. constipation.  21. During a shift report, the nurse learns that she'll be providing care for a client who is vulnerable to panic attack. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as: 

a. barbiturates. b. antianxiety drugs. c. depressants. d. amphetamines.   22. A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by: 

a. staying with the client until the attack subsides. b. telling the client everything is under control. c. telling the client to lie down and rest. d. talking continually to the client by explaining what's happening.  23. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to: 

a. take the client's vital signs. b. explore the content of the hallucinations. 

c. tell him his fear is unrealistic. d. engage the client in reality-oriented activities.   24. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should: 

a. tell him that she'll leave for now but will return soon. b. ask him if it's okay if she sits quietly with him. c. ask him why he wants to be left alone. d. tell him that she won't let anything happen to him. 

25. Tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as: 

a. psychotic symptoms b. parkinsonism c. akathisia d. dystonia 

26. The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: 

a. benztropine (Cogentin). b. diphenhydramine (Benadryl). c. propranolol (Inderal). d. haloperidol (Haldol).   27. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? 

a. Monthly blood tests will be necessary. b. Report a sore throat or fever to the physician immediately. c. Blood pressure must be monitored for hypertension. d. Stop the medication when symptoms subside.  28. A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? 

a. Calcium b. Sodium c. Chloride d. Potassium  29. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate? 

a. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you." b. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." c. "You're wrong. Nobody is trying to kill you." d. "A foreign government is trying to kill you? Please tell me more about it."  30. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which finding should alert the nurse that the client is experiencing pseudoparkinsonism? 

a. Restlessness, difficulty sitting still, pacing b. Involuntary rolling of the eyes c. Tremors, shuffling gait, mask like face d. Extremity and neck spasms, facial grimacing, jerky movements 

31. A 54-year-old female was found unconscious on the floor of her bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate? 

a. Observing for extrapyramidal symptoms b. Beginning a therapeutic relationship c. Canceling any no-suicide contracts d. Continuing suicide precautions  32. A 26-year-old male reports losing his sight in both eyes. He's diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client? 

a. Not focusing on his blindness b. Providing self-care for him c. Telling him that his blindness isn't real d. Teaching eye exercises to strengthen his eyes  33. A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement? 

a. Provide an unstructured environment for the client. b. Rotate the nurses who are assigned to the client. c. Ignore the client's behaviors. d. Bend unit rules to meet the client's needs. 

 34. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: 

a. not occur at all because the time period for their occurrence has passed. b. begin anytime within the next 1 to 2 days. c. begin within 2 to 7 days. d. begin after 7 days.  35. Which of the following factors would have the most influence on the outcome of a crisis situation? 

a. Age b. Previous coping skills c. Self-esteem d. Perception of the problem

36. The nurse is caring for an elderly client in a long-term care facility. The client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first? 

a. Setting aside time to listen to the client b. Removing items that the client could use in a suicide attempt c. Communicating a nonjudgmental attitude d. Referring the client to a mental health professional  37. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder? 

a. Wearing tight-fitting clothing b. Increased blood pressure c. Oily skin d. Excessive and ritualized exercise  38. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? 

a. The student discusses conflicts over drug use. b. The student accepts a referral to a substance abuse counselor. c. The student agrees to inform his parents of the problem. d. The student reports increased comfort with making choices. 

 39. The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The purpose of these techniques is to help the child: 

a. internalize his feelings about death and dying. b. accept responsibility for his situation. c. express feelings that he can't articulate. d. have a good time while he's in the hospital.  40. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client? 

a. Abstinence is the basis for successful treatment. b. Attendance at Alcoholics Anonymous (AA) meetings every day will cure alcoholism. c. For treatment to be successful, family members must participate. d. An occasional social drink is acceptable behavior for the alcoholic.  

41. One staff member in a psychiatric unit says to the nurse, "Why are we carrying out suicide precautions for someone who is dying? It's pointless and a waste of time." The nurse should: 

a. Assign the staff member to other clients. b. Ask the psychiatric clinical nurse specialist to meet with the staff member. c. Agree with the staff member and discontinue suicide precautions.d. Call for a multidisciplinary staff meeting.  42. The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I can't sleep." An initial outcome for this client is that the client will: 

a. Describe adaptive methods of coping to induce sleep. b. Verbalize negative effects of alcohol on the body. c. Describe dangerous effects when combining alcohol and antidepressant medication. d. Verbalize the desire to stop drinking alcohol.  43. The nurse will conduct a psycho educational group for family members about depression. Which of the following topics would be of little help to the family members? 

a. Managing the depressed client at home. b. Drug classifications. c. Support and self-help groups. d. Education about depression.  44. In teaching a client about Alcoholics Anonymous, the nurse states

that Alcoholics Anonymous has helped in the rehabilitation of many alcoholics, probably because many people find it easier to change their behavior when they: 

a. Have the support of rehabilitated alcoholics. b. Know that rehabilitated alcoholics will sympathize with them. c. Can depend on rehabilitated alcoholics to help them identify personal problems related to alcoholism. d. Realize that rehabilitated alcoholics will help them develop defense mechanisms to cope with their alcoholism.  45. A client walks into the mental health clinic and states to the nurse, "I guess I can't make it without my wife. I can't even sleep without her." Which of the following responses by the nurse would be most therapeutic? 

a. "Things always look worse before they get better." b. "I'd say that you're not giving yourself a fair chance." c. "I'll ask the doctor for some sleeping pills for you." d. "Tell me more about what you mean when you say you can't make it without your wife." 

 46. During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband." Which of the following reasons would the client be LEAST likely to mention? 

a. "I'm responsible for keeping my family together." b. "When it's not too bad, the abuse adds spice to our relationship." c. "I love my husband."d. "I'm not sure I could get a job that pays even minimum wage."  47. During a home visit, the client tells the nurse she's not taking prescribed doses of haloperidol (Haldol) because she's tired of bothering with it and doesn't need it. The nurse's best action is to: 

a. Explain the negative effects of skipping the medication. b. Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections. c. Have the client's family begin commitment procedures so that her medication regimen can be supervised more closely. d. Refer the client to a partial hospitalization program so that she can participate regularly in group therapy sessions. 

 48. The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse: 

a. Gives the medication as ordered. b. Questions the physician about the order. 

c. Questions the dosage ordered. d. Asks the physician to order benztropine (Cogentin) for the side effects.  49. A voluntary client has been taking haloperidol (Haldol) as prescribed. One morning, she refuses to take the Haldol. Which of the following actions should the nurse take? 

a. Summon another nurse to help ensure that the client takes her medicine. b. Tell the client that she can take the medication either orally or by injection. c. Withhold the medication until it is determined why the client is refusing to take it. d. Tell the client that she needs to take her "vitamin" to stay healthy.  50. The client is taking fluoxetine (Prozac) 20 mg at bedtime. He states that Prozac is not helping him to sleep. The nurse judges: 

a. That the client should take Prozac in the morning. b. That dose is too high. c. That the client's symptoms of depression seem to be getting worse. d. That the client is on the wrong medication.

PART 5 ANSWERS

1. b. hallucinations. 

2. d. observe him. 

3. c. Set up a strict eating plan for the client. 

4. c. "How do you think you would kill yourself?" 

5. a. dilated pupils and slurred speech. 

6. c. staying with the client and speaking in short sentences. 

7. b. a manic client. 

8. a. highly important or famous. 

9. a. hyper alertness and sleep disturbances.

10. d. listening attentively with a neutral attitude and avoiding power struggles. 

11. a. The opportunity to verbalize memories of trauma to a sympathetic listener 

12. d. Denial 

13. a. Inability to make choices and decisions without advice 

14. d. perceptual disorders. 

15. b. Paranoid thoughts 

16. b. Reducing his stimulation 

17. c. identify anxiety-causing situations. 

18. c. Generates new levels of awareness 

19. c. Polyuria 

20.a. tension and irritability.

21. b. antianxiety drugs. 

22. a. staying with the client until the attack subsides.

23. b. explore the content of the hallucinations. 

24. a. tell him that she'll leave for now but will return soon. 

25. d. dystonia 

26. a. benztropine (Cogentin). 

27. b. Report a sore throat or fever to the physician immediately. 

28. b. Sodium 

29. d. "A foreign government is trying to kill you? Please tell me more about it." 

30. b. Involuntary rolling of the eyes 

31. d. Continuing suicide precautions 

32. a. Not focusing on his blindness 

33. b. Rotate the nurses who are assigned to the client. 

34. b. begin anytime within the next 1 to 2 days. 

35. b. Previous coping skills 

36. b. Removing items that the client could use in a suicide attempt 

37. d. Excessive and ritualized exercise 

38. b. The student accepts a referral to a substance abuse counselor. 

39. c. express feelings that he can't articulate. 

40. a. Abstinence is the basis for successful treatment. 

41. d. Call for a multidisciplinary staff meeting. 

42. d. Verbalize the desire to stop drinking alcohol. 

43. a. Managing the depressed client at home. 

44. a. Have the support of rehabilitated alcoholics. 

45. d. "Tell me more about what you mean when you say you can't make it without your wife." 

46. a. "I'm responsible for keeping my family together." 

47. b. Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections. 

48. b. Questions the physician about the order. 

49. c. Withhold the medication until it is determined why the client is refusing to take it.

50. a. That the client should take Prozac in the morning. 

PART 6

1. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:

A. an example of presenting reality.B. reinforcing the client's delusions.C. focusing on emotional content.D. a nontherapeutic technique called mind reading.

Rationale: The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic.

2. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the

government of France is trying to assassinate him. Which of the following responses is most appropriate?

A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you."B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."C. "You're wrong. Nobody is trying to kill you."D. "A foreign government is trying to kill you? Please tell me more about it."

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

3. Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?

A. Antipsychotic-induced akathisia and anxietyB. The manic phase of bipolar illness as a mood stabilizerC. Delusions for clients suffering from schizophreniaD. Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior

Rationale: Propranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic induced akathisia and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.

4. A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger?

A. "If it had been your emergency, I would have made the other client wait."B. "I know it's frustrating to wait. I'm sorry this happened."C. "You had to wait. Can we talk about how this is making you feel right now?"D. "I really care about you and I'll never let this happen again."

Rationale: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option A wouldn't address the client's anger. Option B is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the

client's misconceptions. The nurse can't promise that a delay will never occur again, as in option D, because such matters are outside the nurse's control.

5. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated

A. Several minutesB. Several hoursC. Several daysD. Several weeks

Rationale: Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.

6. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:

A. reassure the client and administer as needed lorazepam (Ativan) I.M.B. administer as needed dose of benztropine (Cogentin) I.M. as ordered.C. administer as needed dose of benztropine (Cogentin) by mouth as ordered.D. administer as needed dose of haloperidol (Haldol) by mouth.

Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.

7. A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those pills?" Which of the following is the best response?

A. Say, "You know it's your medicine."B. Allow him to open the individual wrappers of the medication.C. Say, "Don't worry about what is in the pills. It's what is ordered."D. Ignore the comment because it's probably a joke.

Rationale: Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A is incorrect because the client doesn't know that it's his medication and he's obviously suspicious. Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance.

8. The nurse is caring for a client with schizophrenia who experiences

auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

A. Approach the client and touch him to get his attention.B. Encourage the client to go to his room where he'll experience fewer distractions.C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.D. Ask the client to describe what the voices are saying.

Rationale: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

9. Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

A. Assume that the client is posturing.B. Tell the client to lie down and relax.C. Evaluate the client for adverse reactions to haloperidol.D. Put the client on the list for the physician to see tomorrow

Rationale: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn't the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait.

10. A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to: 

A. take an as-needed dose of psychotropic medication whenever they hear voices.B. practice saying "Go away" or "Stop" when they hear voices.

C. sing loudly to drown out the voices and provide a distraction.D. go to their room until the voices go away.

Rationale: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.

11. A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

A. Assist the client with feeding.B. Assist the client with showering.C. Reassure the client about safety.D. Encourage socialization with peers.

Rationale: According to Maslow's hierarchy of needs, the need for food is among the most important. Other needs, in order of decreasing importance, include hygiene, safety, and a sense of belonging.

12. A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client is experiencing:

A. a delusion.B. flight of ideas.C. ideas of reference.D. a hallucination.

Rationale: Ideas of reference refers to the mistaken belief that neutral stimuli have special meaning to the individual such as the television newscaster sending a message directly to the individual. A delusion is a false belief. Flight of ideas is a speech pattern in which the client skips from one unrelated subject to another. A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences.

13. The nurse knows that the physician has ordered the liquid form of the drug chlorpromazine (Thorazine) rather than the tablet form because the liquid:

A. has a more predictable onset of action.B. produces fewer anticholinergic effects.C. produces fewer drug interactions.

D. has a longer duration of action.

Rationale: A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

14. A client who has been hospitalized with disorganized type schizophrenia for 8 years can't complete activities of daily living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient: Dressing/grooming related to inability to function without assistance. What is an appropriate goal for this client?

A. "Client will be able to complete ADLs independently within 1 month."B. "Client will be able to complete ADLs with only verbal encouragement within 1 month."C. "Client will be able to complete ADLs with assistance in organizing grooming items and clothing within 1 month."D. "Client will be able to complete ADLs with complete assistance within 1 month."

Rationale: The client's disorganized personality and history of hospitalization have affected the ability to perform self-care activities. Interventions should be directed at helping the client complete ADLs with the assistance of staff members, who can provide needed structure by helping the client select grooming items and clothing. This goal promotes realistic independence. As the client improves and achieves the established goal, the nurse can set new goals that focus on the client completing ADLs with only verbal encouragement and, ultimately, completing them independently. The client's condition doesn't indicate a need for complete assistance, which would only foster dependence.

15. The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?

A. Risk for violence toward self or othersB. Imbalanced nutrition: Less than body requirementsC. Ineffective family copingD. Impaired verbal communication

Rationale: Because of such factors as suspiciousness, anxiety, and hallucinations, the client with paranoid schizophrenia is at risk for violence toward himself or others. The other options are also appropriate nursing diagnoses but should be addressed after the safety of the client and those around him is established.

16. The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse should inform him that:

A. his concern is valid but his wife is an adult and has the right to make her own decisions.B. he can easily mix the medication in his wife's food if she stops taking it.C. his wife can be given a long-acting medication that is administered every 1 to 4 weeks.D. his wife knows she must take her medication as prescribed to avoid future hospitalizations.

Rationale: Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. A client has the right to refuse medication, but this issue isn't the focus of discussion at this time. Medication should never be hidden in food or drink to trick the client into taking it; besides destroying the client's trust, doing so would place the client at risk for overmedication or undermedication because the amount administered is hard to determine. Assuming the client knows she must take the medication to avoid future hospitalizations would be unrealistic.

17. Benztropine (Cogentin) is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by:

A. decreasing the anxiety causing muscle rigidity.B. blocking the cholinergic activity in the central nervous system (CNS).C. increasing the level of acetylcholine in the CNS.D. increasing norepinephrine in the CNS.

Rationale: Option B is the action of Cogentin. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.

18. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?

A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you."B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."C. "You're wrong. Nobody is trying to kill you."D. "A foreign government is trying to kill you? Please tell me more about it."

Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't

therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

19. A dopamine receptor agonist such as bromocriptine (Parlodel) relieves muscle rigidity caused by antipsychotic medication by:

A. blocking dopamine receptors in the central nervous system (CNS).B. blocking acetylcholine in the CNS.C. activating norepinephrine in the CNS.D. activating dopamine receptors in the CNS.

Rationale: Extrapyramidal effects and the muscle rigidity induced by antipsychotic medications are caused by a low level of dopamine. Dopamine receptor agonists stimulate dopamine receptors and thereby reduce rigidity. They don't affect norepinephrine or acetylcholine.

20. Most antipsychotic medications exert which of following effects on the central nervous system (CNS)?

A. Stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors.B. Sedate the CNS by stimulating serotonin at the synaptic cleft.C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.D. Depress the CNS by stimulating the release of acetylcholine.

Rationale: The exact mechanism of antipsychotic medication action is unknown, but appear to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. They don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.

21. A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next several days, the client is seen laughing, yelling, and talking to herself. This behavior is characteristic of:

A. delusion.B. looseness of association.C. illusion.D. hallucination.

Rationale: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of

thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.

22. Which of the following medications would the nurse expect the physician to order to reverse a dystonic reaction?

A. prochlorperazine (Compazine)B. diphenhydramine (Benadryl)C. haloperidol (Haldol)D. midazolam (Versed)

Rationale: Diphenhydramine, 25 to 50 mg I.M. or I.V., would quickly reverse this condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make this client drowsy.

23. A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be most therapeutic?

A. "I don't hear the voice, but I know you hear what sounds like a voice." B. "You shouldn't focus on that voice."C. "Don't worry about the voice as long as it doesn't belong to anyone real."D. "King Tut has been dead for years."

Rationale: This response states reality about the client's hallucination. The other options are judgmental, flippant, or dismissive.

24. A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:

A. an example of presenting reality.B. reinforcing the client's delusions.C. focusing on emotional content.D. a nontherapeutic technique called mind reading.

Rationale: The nurse should help the client focus on the emotional content rather than delusional material. Presenting reality isn't helpful because it can lead to confrontation and disengagement. Agreeing with the client and supporting his beliefs are reinforcing delusions. Mind reading isn't therapeutic.

25. The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing intervention is the most appropriate?

A. Approach the client and touch him to get his attention.B. Encourage the client to go to his room where he'll experience fewer distractions.C. Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.D. Ask the client to describe what the voices are saying

Rationale: By acknowledging that the client hears voices, the nurse conveys acceptance of the client. By letting the client know that the nurse doesn't hear the voices, the nurse avoids reinforcing the hallucination. The nurse shouldn't touch the client with schizophrenia without advance warning. The hallucinating client may believe that the touch is a threat or act of aggression and respond violently. Being alone in his room encourages the client to withdraw and may promote more hallucinations. The nurse should provide an activity to distract the client. By asking the client what the voices are saying, the nurse is reinforcing the hallucination. The nurse should focus on the client's feelings, rather than the content of the hallucination.

26. A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism?

A. Restlessness, difficulty sitting still, and pacingB. Involuntary rolling of the eyesC. Tremors, shuffling gait, and masklike faceD. Extremity and neck spasms, facial grimacing, and jerky movements

Rationale: Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.

27. For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride (Prolixin) by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?

A. Give the next dose of fluphenazine, call the physician, and monitor vital signs.B. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.

C. Give the next dose of fluphenazine and restrict the client to the room to decrease stimulation.D. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

Rationale: Malignant neuroleptic syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because it may increase the client's fluid volume further, raising blood pressure even higher.

28. A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be the best response?

A. "This subject seems to be troubling you. Let's walk to the activity room."B. "Describe the man who's out to get you. What does he look like?"C. "There is no reason to be afraid of that man. This hospital is very secure."D. "There is no need to be concerned with a man who isn't even real."

Rationale: This remark distracts the client from the delusion by engaging the client in a less threatening or more comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the false belief. The other options focus on the content of the delusion rather than the meaning, feeling, or intent that it provokes.

29. Important teaching for women in their childbearing years who are receiving antipsychotic medications includes which of the following?

A. Occurrence of increased libido due to medication adverse effectsB. Increased incidence of dysmenorrhea while taking the drugC. Continuing previous use of contraception during periods of amenorrheaD. Instruction that amenorrhea is irreversible

Rationale: Women may experience amenorrhea, which is reversible, while taking antipsychotics. Amenorrhea doesn't indicate cessation of ovulation; therefore, the client can still become pregnant. The client should be instructed to continue contraceptive use even when experiencing amenorrhea. Dysmenorrhea isn't an adverse effect of antipsychotics, and libido generally decreases because of the depressant effect.

30. A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client has been taking neuroleptic medication for many years. Assessment reveals

unusual movements of the tongue, neck, and arms. Which condition should the nurse suspect?

A. Tardive dyskinesiaB. DystoniaC. Neuroleptic malignant syndromeD. Akathisia

Rationale: Unusual movements of the tongue, neck, and arms suggest tardive dyskinesia, an adverse reaction to neuroleptic medication. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Neuroleptic malignant syndrome causes rigidity, fever, hypertension, and diaphoresis. Akathisia causes restlessness, anxiety, and jitteriness.

31. What medication would probably be ordered for the acutely aggressive schizophrenic client?

A. chlorpromazine (Thorazine)B. haloperidol (Haldol)C. lithium carbonate (Lithonate)D. amitriptyline (Elavil)

Rationale: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar or manic disorder, and amitriptyline is used for depression.

32. A client is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?

A. Aggressive behaviorB. Paranoid thoughtsC. Emotional affectD. Independence needs

Rationale: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts. Aggressive behavior is uncommon, although these clients may experience agitation with anxiety. Their behavior is emotionally cold with a flattened affect, regardless of the situation. These clients demonstrate a reduced capacity for close or dependent relationships.

33. During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response?

A. "When people are under stress, they may see things or hear things that others don't. Is that what just happened?"

B. "I'm having a difficult time hearing you. Please look at me when you talk."C. "There is no one else in the room. What are you doing?"D. "Who are you talking to? Are you hallucinating?"

Rationale: This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship. Directing the client to look at the nurse wouldn't address the obvious issue of the hallucination. Confrontational approaches, such as in options C and D, are likely to elicit an uninformative or negative response.

34. The definition of nihilistic delusions is:

A. a false belief about the functioning of the body.B. belief that the body is deformed or defective in a specific way.C. false ideas about the self, others, or the worldD. the inability to carry out motor activities.

Rationale: Nihilistic delusions are false ideas about the self, others, or the world. Somatic delusions involve a false belief about the functioning of the body. Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a specific way. Apraxia is the inability to carry out motor activities.

35. A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what complication of antipsychotic therapy?

A. AgranulocytosisB. Extrapyramidal effectsC. Anticholinergic effectsD. Neuroleptic malignant syndrome (NMS)

Rationale: A rare but potentially fatal condition of antipsychotic medication is called NMS. It generally starts with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Anticholinergic effects include blurred vision, drowsiness, and dry mouth. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism.

36. The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes highest priority?

A. Helping the client to participate in social interactionsB. Establishing a one-on-one relationship with the clientC. Exploring the effects of the client's behavior on social interactions

D. Developing a schedule for the client's participation in social interactions

Rationale: By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate but should take place only after the nurse-client relationship is established.

37. A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing:

A. a delusion.B. flight of ideas.C. ideas of reference.D. a hallucination.

Rationale: A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which the client skips from one unrelated subject to another. Ideas of reference refers to the mistaken belief that someone or something outside the client is controlling the client's ideas or behavior.

38. A client with delusional thinking shows a lack of interest in eating at meal times. She states that she is unworthy of eating and that her children will die if she eats. Which nursing action would be most appropriate for this client?

A. Telling the client that she may become sick and die unless she eatsB. Paying special attention to the client's rituals and emotions associated with mealsC. Restricting the client's access to food except at specified meal and snack timesD. Encouraging the client to express her feelings at meal times

Rationale: Restricting access to food except at specified times prevents the client from eating when she feels anxious, guilty, or depressed; this, in turn, decreases the association between these emotions and food. Telling the client she may become sick or die may reinforce her behavior because illness or death may be her goal. Paying special attention to rituals and emotions associated with meals also would reinforce undesirable behavior. Encouraging the client to express feelings at meal times would increase the association between emotions and food; instead, the nurse should encourage her to express feelings at other times.

39. Which of the following groups of characteristics would the nurse expect to see in the client with schizophrenia?

A. Loose associations, grandiose delusions, and auditory hallucinations

B. Periods of hyperactivity and irritability alternating with depressionC. Delusions of jealousy and persecution, paranoia, and mistrustD. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss

Rationale: Loose associations, grandiose delusions, and auditory hallucinations are all characteristic of the classic schizophrenic client. These clients aren't able to care for their physical appearance. They frequently hear voices telling them to do something either to themselves or to others. Additionally, they verbally ramble from one topic to the next. Periods of hyperactivity and irritability alternating with depression are characteristic of bipolar or manic disease. Delusions of jealousy and persecution, paranoia, and mistrust are characteristics of paranoid disorders. Sadness, apathy, feelings of worthlessness, anorexia, and weight loss are characteristics of depression.

40. The nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is:

A. Benztropine (Cogentin).B. diphenhydramine (Benadryl).C. propranolol (Inderal).D. haloperidol (Haldol).

Rationale: Benztropine, trihexyphenidyl, or amantadine are prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.

41. A client is receiving haloperidol (Haldol) to reduce psychotic symptoms. As he watches television with other clients, the nurse notes that he has trouble sitting still. He seems restless, constantly moving his hands and feet and changing position. When the nurse asks what is wrong, he says he feels jittery. How should the nurse manage this situation?

A. Ask the client to sit still or leave the room because he is distracting the other clients.B. Ask the client if he is nervous or anxious about something.C. Give an as needed dose of a prescribed anticholinergic agent to control akathisia.D. Administer an as needed dose of haloperidol to decrease agitation.

Rationale: Akathisia, characterized by restlessness, is a common but often overlooked adverse reaction to haloperidol and other antipsychotic agents; it may be confused with psychotic agitation. To control akathisia, the nurse should give an as needed dose of a prescribed anticholinergic agent. The client can't control the movements, so asking him to sit still would be pointless. Asking him to

leave the room wouldn't address the underlying cause of the problem. Encouraging him to talk about the symptoms wouldn't stop them from occurring. Giving more antipsychotic medication would worsen akathisia.

42. A man is brought to the hospital by his wife, who states that for the past week her husband has refused all meals and accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals that his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid schizophrenia. Schizophrenia is best described as a disorder characterized by:

A. disturbed relationships related to an inability to communicate and think clearly.B. severe mood swings and periods of low to high activity.C. multiple personalities, one of which is more destructive than the others.D. auditory and tactile hallucinations.

Rationale: Schizophrenia is best described as one of a group of psychotic reactions characterized by disturbed relationships with others and an inability to communicate and think clearly. Schizophrenic thoughts, feelings, and behavior commonly are evidenced by withdrawal, fluctuating moods, disordered thinking, and regressive tendencies. Severe mood swings and periods of low to high activity are typical of bipolar disorder. Multiple personality, sometimes confused with schizophrenia, is a dissociative personality disorder, not a psychotic illness. Many schizophrenic clients have auditory hallucinations; tactile hallucinations are more common in organic or toxic disorders

43. A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?

A. Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occurB. Sitting up for a few minutes before standing to minimize orthostatic hypotensionC. Notifying the physician if her thoughts don't normalize within 1 weekD. Expecting symptoms of tardive dyskinesia to occur and to be transient

Rationale: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive

dyskinesia is a possible adverse reaction and should be reported immediately

44. A client with chronic schizophrenia who takes neuroleptic medication is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. These findings suggest which life-threatening reaction:

A. tardive dyskinesia.B. dystonia.C. neuroleptic malignant syndrome.D. akathisia.

Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, facial muscles, and arm and leg muscles. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

45. While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which of the following terms best describes what the creatures represent?

A. Anxiety attackB. ProjectionC. HallucinationD. Delusion

Rationale: A delusion is a false belief based on a misrepresentation of a real event or experience. Although anxiety can increase delusional responses, it isn't considered the primary symptom. Projection is falsely attributing to another person one's own unacceptable feelings. Hallucinations, which characterize most psychoses, are perceptual disorders of the five senses; the client may see, taste, feel, smell, or hear something in the absence of external stimulation

46. A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a:

A. delusion of persecution.B. delusion of grandeur.C. somatic delusion.D. jealous delusion.

Rationale: Somatic delusions focus on bodily functions or systems and commonly include delusions about foul odor emissions, insect infestations, internal parasites, and misshapen parts. Delusions of persecution are morbid beliefs that one is being mistreated and

harassed by unidentified enemies. Delusions of grandeur are gross exaggerations of one's importance, wealth, power, or talents. Jealous delusions are delusions that one's spouse or lover is unfaithful.

47. During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:

A. somatic delusions.B. waxy flexibility.C. neologisms.D. nihilistic delusions.

Rationale: The correct answer is waxy flexibility, which is defined as retaining any position that the body has been placed in. Somatic delusions involve a false belief about the functioning of the body. Neologisms are invented meaningless words. Nihilistic delusions are false ideas about self, others, or the world.

48. A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should

A. tell him that she'll leave for now but will return soon.B. ask him if it's okay if she sits quietly with him.C. ask him why he wants to be left alone.D. tell him that she won't let anything happen to him

Rationale: If the client tells the nurse to leave, the nurse should leave but let the client know that she'll return so that he doesn't feel abandoned. Not heeding the client's request can agitate him further. Also, challenging the client isn't therapeutic and may increase his anger. False reassurance isn't warranted in this situation

49. Nursing care for a client with schizophrenia must be based on valid psychiatric and nursing theories. The nurse's interpersonal communication with the client and specific nursing interventions must be:

A. clearly identified with boundaries and specifically defined roles.B. warm and nonthreatening.C. centered on clearly defined limits and expression of empathy.D. flexible enough for the nurse to adjust the plan of care as the situation warrants.

Rationale: A flexible plan of care is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or who has a thought disorder. Because such a client communicates at different levels and is in control of himself at various times, the nurse must be able to adjust nursing care as the situation warrants. The nurse's role should be clear; however, the boundaries or limits of this role should be flexible enough to meet client needs. Because a client with schizophrenia fears

closeness and affection, a warm approach may be too threatening. Expressing empathy is important, but centering interventions on clearly defined limits is impossible because the client's situation may change without warning.

50. When discharging a client after treatment for a dystonic reaction, the emergency department nurse must ensure that the client understands which of the following?

A. Results of treatment are rapid and dramatic but may not last.B. Although uncomfortable, this reaction isn't serious.C. The client shouldn't buy drugs on the street.D. The client must take benztropine (Cogentin) as prescribed to prevent a return of symptoms.

Rationale: An oral anticholinergic agent such as benztropine (Cogentin) is commonly prescribed to control and prevent the return of symptoms. Dystonic reactions are typically acute and reversible. Dystonic reactions can be life-threatening when airway patency is compromised. Lecturing the client about buying drugs on the street isn't appropriate

PART 7

1. The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?  A. The client spends more time by himself. B. The client doesn't engage in delusional thinking. C. The client doesn't harm himself or others. D. The client demonstrates the ability to meet his own self-care needs.   2. The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?  A. Helping the client to participate in social interactions B. Establishing a one-on-one relationship with the client  C. Establishing alternative forms of communication D. Allowing the client to decide when he wants to participate in verbal communication with the nurse 

 3. Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?  A. Dismantling the showerhead and showing the client that there is nothing in it B. Explaining that other clients are complaining about the client's body odor 

C. Asking a security officer to assist in giving the client a shower D. Accepting these fears and allowing the client to take a sponge bath   4. Drug therapy with thioridazine (Mellaril) shouldn't exceed a daily dose of 800 mg to prevent which adverse reaction?  A. Hypertension B. Respiratory arrest C. Tourette syndrome D. Retinal pigmentation  5. A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse?  A. "I get upset once in a while, too." B. "I know just how you feel. I'd feel the same way in your situation." C. "I worry, too, when I think people are talking about me." D. "At times, it's normal not to trust anyone."   6. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client's delusional thoughts and hallucinations eliminated?  A. Several minutes B. Several hours C. Several daysD. Several weeks   7. A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client?  A. Take the medication 1 hour before a meal. B. Decrease the dosage if signs of illness decrease. C. Apply a sunscreen before being exposed to the sun. D. Increase the dosage up to 50 mg twice per day if signs of illness don't decrease.   8. A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?  A. "Your behavior won't be tolerated. Go to your room immediately." B. "You're just doing this to get back at me for making you come to therapy." C. "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." D. "I'm disappointed in you. You can't control yourself even for a few

minutes."  9. Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)? 

A. The absence of anticholinergic effects B. A lower incidence of extrapyramidal effects C. Photosensitivity and sedation D. No incidence of neuroleptic malignant syndrome   10. The etiology of schizophrenia is best described by:  A. genetics due to a faulty dopamine receptor. B. environmental factors and poor parenting. C. structural and neurobiological factors. D. a combination of biological, psychological, and environmental factors.    11. A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms?  A. benztropine (Cogentin) B. dantrolene (Dantrium) C. clonazepam (Klonopin) D. diazepam (Valium)   12. A client with a diagnosis of paranoid schizophrenia comments tothe nurse, "How do I know what is really in those pills?" Which of the following is the best response?  A. Say, "You know it's your medicine." B. Allow him to open the individual wrappers of the medication. C. Say, "Don't worry about what is in the pills. It's what is ordered." D. Ignore the comment because it's probably a joke.   13. A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic?  A. "That must be frightening to you. Can you tell me how you feel about it?" B. "There are no people living on Mars." C. "What do you mean when you say they're going to invade the earth?" D. "I know you believe the earth is going to be invaded, but I don't believe that."   14. A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:  

A. sit in a quiet, dark room and concentrate on the voices. B. listen to a personal stereo through headphones and sing along with the music. C. call a friend and discuss the voices and his feelings about them. D. engage in strenuous exercise.   15. A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client?  A. Ineffective protection related to blood dyscrasias B. Urinary frequency related to adverse effects of antipsychotic medication C. Risk for injury related to a severely decreased level of consciousness D. Risk for injury related to electrolyte disturbances   16. A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?  A. Dystonia B. Akathisia C. Pseudoparkinsonism D. Tardive dyskinesia    17. The nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in the client's plan of care?  A. Meeting all of the client's physical needs B. Giving the client an opportunity to express concerns C. Administering lithium carbonate (Lithonate) as prescribed D. Providing a quiet environment where the client can be alone

18. A client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client?  A. chlorpromazine (Thorazine) B. imipramine (Tofranil) C. lithium carbonate (Lithane) D. fluphenazine decanoate (Prolixin Decanoate)   19. Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?  A. Antipsychotic-induced akathisia and anxiety  B. The manic phase of bipolar illness as a mood stabilizer C. Delusions for clients suffering from schizophrenia D. Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior 

  20. Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, "Get out of here right now! The elevator bombs are going to explode in 3 minutes!" The next time this happens, how should the nurse respond?  A. "Why do you think there is a bomb in the elevator?" B. "That is the same thing you said in yesterday's session." C. "I know you think there are bombs in the elevator, but there aren't." D. "If you have something to say, you must do it according to our group rules."   21. A 26-year-old client is admitted to the psychiatric unit with acute onset of schizophrenia. His physician prescribes the phenothiazine chlorpromazine (Thorazine), 100 mg by mouth four times per day. Before administering the drug, the nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects?  A. guanethidine (Ismelin) B. droperidol (Inapsine) C. lithium carbonate (Lithonate) D. alcohol   22. A client, age 36, with paranoid schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?  A. Autonomy versus shame and doubt B. Generativity versus stagnation C. Integrity versus despair D. Trust versus mistrust  23. During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:  A. paranoid personality disorder. B. avoidant personality disorder. C. histrionic personality disorder. D. borderline personality disorder.   24. The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered? 

A. To reduce psychotic symptoms B. To reduce extrapyramidal symptoms C. To control nausea and vomiting D. To relieve anxiety   25. A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes the phenothiazine thioridazine (Mellaril) 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:  A. deeper sleep than CNS depressants. B. greater sedation than CNS depressants. C. a calming effect from which the client is easily aroused. D. more prolonged sedative effects, making the client more difficult to arouse.  26. A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client's speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagnosis?  A. Schizophrenia B. Paranoid personality C. Bipolar illness D. Obsessive-compulsive disorder (OCD)  27. A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client's:  A. thinking, perceiving, and decision-making skills. B. verbal and nonverbal communication processes. C. affect and behavior. D. psychomotor activity.  28. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)? A. Monthly blood tests will be necessary. B. Report a sore throat or fever to the physician immediately. C. Blood pressure must be monitored for hypertension. D. Stop the medication when symptoms subside.   29. Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions?  

A. Use sunscreen because of photosensitivity. B. Take the antipsychotic medication with food. C. Have routine blood tests to determine levels of the medication. D. Abstain from eating aged cheese.   30. Positive symptoms of schizophrenia include which of the following?  A. Hallucinations, delusions, and disorganized thinking B. Somatic delusions, echolalia, and a flat affect C. Waxy flexibility, alogia, and apathy D. Flat affect, avolition, and anhedonia   31. A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction?  A. Dystonia B. Akinesia C. Akathisia D. Tardive dyskinesia  32. Hormonal effects of the antipsychotic medications include which of the following?  A. Retrograde ejaculation and gynecomastia B. Dysmenorrhea and increased vaginal bleeding C. Polydipsia and dysmenorrhea D. Akinesia and dysphasia   33. A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?   A. Word salad B. Tangential C. Perseveration D. Avolition   34. An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used in this client to treat:  A. dyskinesia.B. dementia. C. psychosis. D. tardive dyskinesia. 

  35. Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?  A. Assume that the client is posturing. B. Tell the client to lie down and relax. C. Evaluate the client for adverse reactions to haloperidol. D. Put the client on the list for the physician to see tomorrow.   36. A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy develops pseudoparkinsonism. The physician is likely to prescribe which drug to control this extrapyramidal effect?  A. phenytoin (Dilantin) B. amantadine (Symmetrel) C. benztropine (Cogentin) D. diphenhydramine (Benadryl)  37. Important teaching for a client receiving risperidone (Risperdal) would include advising the client to: 

A. double the dose if missed to maintain a therapeutic level. B. be sure to take the drug with a meal because it's very irritating to the stomach. C. discontinue the drug if the client reports weight gain. D. notify the physician if the client notices an increase in bruising.   38. A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:  A. suggestibility. B. negativity. C. waxy flexibility. D. retardation. 

 39. A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client's anger?  A. "If it had been your emergency, I would have made the other client wait." B. "I know it's frustrating to wait. I'm sorry this happened." C. "You had to wait. Can we talk about how this is making you feel right

now?" D. "I really care about you and I'll never let this happen again."   40. A client begins clozapine (Clozaril) therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?  A. Hepatitis B. Infection C. Granulocytopenia D. Systemic dermatitis 

 41. Which nonantipsychotic medication is used to treat some clients with schizoaffective disorder?  A. phenelzine (Nardil) B. chlordiazepoxide (Librium) C. lithium carbonate (Lithane) D. imipramine (Tofranil)   42. A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders?  A. Personality disorder B. Mood disorder C. Thought disorder D. Amnestic disorder   43. When teaching the family of a client with schizophrenia, the nurse should provide which information?  A. Relapse can be prevented if the client takes the medication. B. Support is available to help family members meet their own needs. C. Improvement should occur if the client has a stimulating environment. D. Stressful family situations can precipitate a relapse in the client.   44. A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:  A. loss of identity and self-esteem. B. multiple personalities and decreased self-esteem. C. disturbances in affect, perception, and thought content and form. D. persistent memory impairment and confusion.   45. The nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:  

A. ask the client which activity he would prefer to do first. B. negotiate a time when the client will perform activities. C. tell the client specifically and concisely what needs to be done. D. prepare the client ahead of time for the activity.   46. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:  A. delusions. B. hallucinations. C. loose associations. D. neologisms. 

 47. The nurse is aware that antipsychotic medications may cause which of the following adverse effects?  A. Increased production of insulin B. Lower seizure threshold C. Increased coagulation time D. Increased risk of heart failure  48. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:  A. highly important or famous. B. being persecuted. C. connected to events unrelated to oneself. D. responsible for the evil in the world.   49. A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign highest priority to which nursing diagnosis?  A. Anxiety B. Impaired verbal communication C. Disturbed thought processes D. Self-care deficient: Dressing/grooming   50. A client's medication order reads, "Thioridazine (Mellaril) 200 mg P.O. q.i.d. and 100 mg P.O. p.r.n." The nurse should:  A. administer the medication as prescribed. B. question the physician about the order. C. administer the order for 200 mg P.O. q.i.d. but not for 100 mg P.O. p.r.n. D. administer the medication as prescribed but observe the client closely for adverse effects.

PART 7 ANSWERS

1. A. The client spends more time by himself. Rationale: The client with schizophrenia is commonly socially isolated and withdrawn; therefore, having the client spend more time by himself wouldn't be a desirable outcome. Rather, a desirable outcome would specify that the client spend more time with other clients and staff on the unit. Delusions are false personal beliefs. Reducing or eliminating delusional thinking using talking therapy and antipsychotic medications would be a desirable outcome. Protecting the client and others from harm is a desirable client outcome achieved by close observation, removing any dangerous objects, and administering medications. Because the client with schizophrenia may have difficulty meeting his or her own self-care needs, fostering the ability to perform self-care independently is a desirable client outcome.  2. B. Establishing a one-on-one relationship with the client  Rationale: By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. The other options are appropriate but should take place only after the nurse-client relationship is established.  3. D. Accepting these fears and allowing the client to take a sponge bath Rationale: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality (as in option A) wouldn't be effective at this time. Options B and C would violate the client's rights by shaming or embarrassing the client.  4.D. Retinal pigmentation Rationale: Retinal pigmentation may occur if the thioridazine dosage exceeds 800 mg per day. The other options don't occur as a result of exceeding this dose.   5. A. "I get upset once in a while, too." Rationale: Sharing a benign, nonthreatening, personal fact or feeling helps the nurse establish rapport and encourages the client to confide in the nurse. The nurse can't know how the client feels. Telling the client otherwise, as in option B, would justify the suspicions of a paranoid client; furthermore, the client relies on the nurse to interpret reality. Option C is incorrect because it focuses on the nurse's feelings, not the client's. Option D wouldn't help establish rapport or encourage the client to confide in the nurse  6. D. Several weeks Rationale: Although most phenothiazines produce some effects within minutes to hours, their antipsychotic effects may take several weeks to appear.  7. C. Apply a sunscreen before being exposed to the sun. 

Rationale: Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse also should teach the client to take haloperidol with meals — not 1 hour before — and should instruct the client not to decrease or increase the dosage unless the physician orders it  8. A. "Your behavior won't be tolerated. Go to your room immediately." Rationale: The nurse should set limits on client behavior to ensure a comfortable environment for all clients. The nurse should accept hostile or quarrelsome client outbursts within limits without becoming personally offended, as in option A. Option B is incorrect because it implies that the client's actions reflect feelings toward the staff instead of the client's own misery. Judgmental remarks, such as option D, may decrease the client's self-esteem.  9. B. A lower incidence of extrapyramidal effects Rationale: Risperdal has a lower incidence of extrapyramidal effects than the typical antipsychotics. Risperdal does produce anticholinergic effects and neuroleptic malignant syndrome can occur. Photosensitivity isn't an advantage.  10. D. a combination of biological, psychological, and environmental factors.  Rationale: A reliable genetic marker hasn't been determined for schizophrenia. However, studies of twins and adopted siblings have strongly implicated a genetic predisposition. Since the mid-19th century, excessive dopamine activity in the brain has also been suggested as a causal factor. Communication and the family system have been studied as contributing factors in the development of schizophrenia. Therefore, a combination of biological, psychological, and environmental factors are thought to cause schizophrenia.  11. A. benztropine (Cogentin) Rationale: Benztropine is an anticholinergic drug administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin drug that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine drug that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine drug, is administered to reduce anxiety.  12. B. Allow him to open the individual wrappers of the medication. Rationale: Option B is correct because allowing a paranoid client to open his medication can help reduce suspiciousness. Option A is incorrect because the client doesn't know that it's his medication and

he's obviously suspicious. Telling the client not to worry or ignoring the comment isn't supportive and doesn't offer reassurance.  13. A. "That must be frightening to you. Can you tell me how you feel about it?" Rationale: This response addresses the client's underlying fears without feeding the delusion. Refuting the client's delusion, as in option B, would increase anxiety and reinforce the delusion. Asking the client to elaborate on the delusion, as in option C, would also reinforce it. Voicing disbelief about the delusion, as in option D, wouldn't help the client deal with underlying fears  14. B. listen to a personal stereo through headphones and sing along with the music. Rationale: Increasing the amount of auditory stimulation, such as by listening to music through headphones, may make it easier for the client to focus on external sounds and ignore internal sounds from auditory hallucinations. Option A would make it harder for the client to ignore the hallucinations. Talking about the voices, as in option C, would encourage the client to focus on them. Option D is incorrect because exercise alone wouldn't provide enough auditory stimulation to drown out the voices.  15. A. Ineffective protection related to blood dyscrasias Rationale: Antipsychotic medications may cause neutropenia and granulocytopenia, life-threatening blood dyscrasias, that warrant a nursing diagnosis of Ineffective protection related to blood dyscrasias. These medications also have anticholinergic effects, such as urine retention, dry mouth, and constipation. Urinary frequency isn't an approved nursing diagnosis. Although antipsychotic medications may cause sedation, they don't severely decrease the level of consciousness, eliminating option C. These drugs don't cause electrolyte disturbances, eliminating option D.  16. D. Tardive dyskinesia  Rationale: An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that commonly are irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease.  17. A. Meeting all of the client's physical needs Rationale: Because a client with catatonic schizophrenia can't meet physical needs independently, the nurse must provide for all of these needs, including adequate food and fluid intake, exercise, and elimination. This client is incapable of expressing concerns; however, the nurse should try to verbalize the message conveyed by the client's nonverbal behavior. Lithium is used to treat mania, not catatonic schizophrenia. Despite the client's mute, unresponsive state, the nurse should provide nonthreatening stimulation and should spend time with

the client, not leave the client alone all the time. Although aware of the environment, the client doesn't interact with it actively; the nurse's support and presence can be reassuring.  18. D. fluphenazine decanoate (Prolixin Decanoate) Rationale: Fluphenazine decanoate is a long-acting antipsychotic agent given by injection. Because it has a 4-week duration of action, it's commonly prescribed for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.  19. A. Antipsychotic-induced akathisia and anxiety  Rationale: Propranolol is a potent beta-adrenergic blocker and produces a sedating effect; therefore, it's used to treat antipsychotic induced akathisia and anxiety. Lithium (Lithobid) is used to stabilize clients with bipolar illness. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.  20. C. "I know you think there are bombs in the elevator, but there aren't." Rationale: Option C is the most therapeutic response because it orients the client to reality. Options A and B are condescending. Option D sounds punitive and could embarrass the client.  21. B. droperidol (Inapsine) Rationale: When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. The other options are incorrect  22. D. Trust versus mistrust Rationale: This client's paranoid ideation indicates difficulty trusting others. The stage of autonomy versus shame and doubt deals with separation, cooperation, and self-control. Generativity versus stagnation is the normal stage for this client's chronologic age. Integrity versus despair is the stage for accepting the positive and negative aspects of one's life, which would be difficult or impossible for this client. 

23. C. histrionic personality disorder. Rationale: This client's behaviors are typical of histrionic personality disorder, which is marked by excessive emotionality and attention seeking. The client constantly seeks and demands attention, approval, or praise; may be seductive in behavior, appearance, or conversation; and is uncomfortable except when she is the center of attention. Typically, a client with paranoid personality disorder is suspicious, cold, hostile, and argumentative. Avoidant personality disorder is characterized by anxiety, fear, and social isolation. Borderline

personality disorder is characterized by impulsive, unpredictable behavior and unstable, intense interpersonal relationships.  24. B. To reduce extrapyramidal symptoms Rationale: Benztropine is an anticholinergic medication, administered to reduce the extrapyramidal adverse effects of chlorpromazine and other antipsychotic medications. Benztropine doesn't reduce psychotic symptoms, relieve anxiety, or control nausea and vomiting.  25. C. a calming effect from which the client is easily aroused. Rationale: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.   26. C. Bipolar illness Rationale: Bipolar illness is characterized by mood swings from profound depression to elation and euphoria. Delusions of grandeur along with pressured speech are common symptoms of mania. Schizophrenia doesn't exhibit mood swings from depression to euphoria. Paranoia is characterized by unrealistic suspiciousness and is often accompanied by grandiosity. OCD is a preoccupation with rituals and rules.  27. A. thinking, perceiving, and decision-making skills. Rationale: Nursing assessment of a psychotic client should include careful inquiry about and observation of the client's thinking, perceiving, symbolizing, and decision-making skills and abilities. Assessment of such a client typically reveals alterations in thought content and process, perception, affect, and psychomotor behavior; changes in personality, coping, and sense of self; lack of self-motivation; presence of psychosocial stressors; and degeneration of adaptive functioning. Although assessing communication processes, affect, behavior, and psychomotor activity would reveal important information about the client's condition, the nurse should concentrate on determining whether the client is hallucinating by assessing thought processes and decision-making ability.  28. B. Report a sore throat or fever to the physician immediately. Rationale: A sore throat and fever are indications of an infection caused by agranulocytosis, a potentially life-threatening complication of clozapine. Because of the risk of agranulocytosis, white blood cell (WBC) counts are necessary weekly, not monthly. If the WBC count drops below 3,000/µl, the medication must be stopped. Hypotension may occur in clients taking this medication. Warn the client to stand up slowly to avoid dizziness from orthostatic hypotension. The medication should be continued, even when symptoms have been controlled. If the medication must be stopped, it should be slowly tapered over 1 to 2 weeks and only under the supervision of a physician. 

 29. A. Use sunscreen because of photosensitivity.       B. Take the antipsychotic medication with food. * A and B are both correct in taking HALDOL.  30. A. Hallucinations, delusions, and disorganized thinking Rationale: The positive symptoms of schizophrenia are distortions of normal functioning. Option A lists the positive symptoms of schizophrenia. A flat affect, alogia, apathy, avolition, and anhedonia refer to the negative symptoms. Negative symptoms list the diminution or loss of normal function  31. A. Dystonia Rationale: Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements, particularly around the mouth.  32. A. Retrograde ejaculation and gynecomastia Rationale: Decreased libido, retrograde ejaculation, and gynecomastia are all hormonal effects that can occur with antipsychotic medications. Reassure the client that the effects can be reversed or that changing medication may be possible. Polydipsia, akinesia, and dysphasia aren't hormonal effects.  33. D. Avolition Rationale: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is when a group of words are put together in a random fashion without logical connection. Tangential is where a person never gets to the point of the communication. Perseveration is when a person repeats the same word or idea in response to different questions.  34. C. psychosis. Rationale: By treating psychosis, haloperidol, an antipsychotic drug, decreases agitation. Haloperidol is used to treat dyskinesia in clients with Tourette syndrome and to treat dementia in elderly clients. Tardive dyskinesia may occur after prolonged haloperidol use; the client should be monitored for this adverse reaction.  35. C. Evaluate the client for adverse reactions to haloperidol. Rationale: An antipsychotic agent, such as haloperidol, can cause muscle spasms in the neck, face, tongue, back, and sometimes legs as well as torticollis (twisted neck position). The nurse should be aware of these adverse reactions and assess for related reactions promptly. Although posturing may occur in clients with schizophrenia, it isn't the same as neck and jaw spasms. Having the client relax can reduce tension-induced muscle stiffness but not drug-induced muscle spasms. When a client develops a new sign or symptom, the nurse should

consider an adverse drug reaction as the possible cause and obtain treatment immediately, rather than have the client wait.  36. B. amantadine (Symmetrel) Rationale: An antiparkinsonian agent, such as amantadine, may be used to control pseudoparkinsonism; diphenhydramine or benztropine may be used to control other extrapyramidal effects. Phenytoin is used to treat seizure activity.  37. D. notify the physician if the client notices an increase in bruising. Rationale: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. Don't double the dose. This drug doesn't irritate the stomach, and weight gain isn't a problem.  38. C. waxy flexibility. Rationale: Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia. Clients commonly remain in these awkward positions until someone repositions them. Clients with dependency problems may demonstrate suggestibility, a response pattern in which one easily agrees to the ideas and suggestions of others rather than making independent judgments. Negativity (for example, resistance to being moved or being asked to cooperate) and retardation (slowed movement) also occur in catatonic clients.  39. C. "You had to wait. Can we talk about how this is making you feel right now?" Rationale: This response may diffuse the client's anger by helping to maintain a therapeutic relationship and addressing the client's feelings. Option A wouldn't address the client's anger. Option B is incorrect because the client with a borderline personality disorder blames others for things that happen, so apologizing reinforces the client's misconceptions. The nurse can't promise that a delay will never occur again, as in option D, because such matters are outside the nurse's control.  40. C. Granulocytopenia Rationale: Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions of clozapine therapy.  41. C. lithium carbonate (Lithane) Rationale: Lithium carbonate, an antimania drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including maniclike activity. Lithium helps control the affective component of this disorder. Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don't respond to other

antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and those undergoing cocaine detoxification.  42. B. Mood disorder Rationale: According to the DSM-IV, schizoaffective disorder refers to clients suffering from schizophrenia with elements of a mood disorder, either mania or depression. The prognosis is generally better than for the other types of schizophrenia, but it's worse than the prognosis for a mood disorder alone. Option A is incorrect because personality disorders and psychotic illness aren't listed together on the same axis. Option C is incorrect because schizophrenia is a major thought disorder and the question asks for elements of another disorder. Clients with schizoaffective disorder aren't suffering from schizophrenia and an amnestic disorder.  43. B. Support is available to help family members meet their own needs. Rationale: Because family members of a client with schizophrenia face difficult situations and great stress, the nurse should inform them of support services that can help them cope with such problems. The nurse should also teach them that medication can't prevent relapses and that environmental stimuli may precipitate symptoms. Although stress can trigger symptoms, the nurse shouldn't make the family feel responsible for relapses (as in option D).  44. C. disturbances in affect, perception, and thought content and form. Rationale: The Diagnostic and Statistic Manual of Mental Disorders, 4th edition, defines schizophrenia as a disturbance in multiple psychological processes that affects thought content and form, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behavior. Loss of identity sometimes occurs but is only one characteristic of the disorder. Multiple personalities typify multiple personality disorder, a dissociative personality disorder. Mood disorders are commonly accompanied by increased or decreased self-esteem. Schizophrenia doesn't cause a disturbance in sensorium, although the client may exhibit confusion, disorientation, and memory impairment during the acute phase.  45. C. tell the client specifically and concisely what needs to be done. Rationale: The client needs to be informed of the activity and when it will be done. Giving the client choices isn't desirable because he can be manipulative or refuse to do anything. Negotiating and preparing the client ahead of time also isn't therapeutic with this type of client because he may not want to perform the activity.  46. B. hallucinations. 

Rationale: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real. Loose associations are rapid shifts among unrelated ideas. Neologisms are bizarre words that have meaning only to the client.  47. B. Lower seizure threshold Rationale: Antipsychotic medications exert an effect on brain neurotransmitters that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect ofantipsychotic agents  48. A. highly important or famous. Rationale: A delusion of grandeur is a false belief that one is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.  49. A. Anxiety Rationale: For this client, the highest-priority nursing diagnosis is Anxiety (severe to panic-level), manifested by the client's extreme withdrawal and attempt to protect himself from the environment. The nurse must act immediately to reduce anxiety and protect the client and others from possible injury. Impaired verbal communication, manifested by noncommunicativeness; Disturbed thought processes, evidenced by inability to understand the situation; and Self-care deficient: Dressing/grooming, evidenced by a disheveled appearance, are appropriate nursing diagnoses but aren't the highest priority  50. B. question the physician about the order. Rationale: The nurse must question this order immediately. Thioridazine (Mellaril) has an absolute dosage ceiling of 800 mg/day. Any dosage above this level places the client at high risk for toxic pigmentary retinopathy, which can't be reversed. As written, the order allows for administering more than the maximum 800 mg/day; it should be corrected immediately, before the client's health is jeopardized. 

PART 8

1. An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis?  

A. Flat affect, social withdrawal, and unusual dress B. Suspiciousness, hypervigilance, and emotional coldness C. Lack of self-esteem, strong dependency needs, and impulsive behavior D. Insensitivity to others, sexual acting out, and violence  2.In a toddler, which of the following injuries is most likely the result of child abuse?  A. A hematoma on the occipital region of the head B. A 1-inch forehead laceration C. Several small, dime-sized circular burns on the child's back D. A small isolated bruise on the right lower extremity   3. A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4" (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has:  A. bulimia nervosa. B. anorexia nervosa. C. depression. D. schizophrenia.   4. A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse?  A. "You don't have to eat. It's your choice." B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable." C. "Why do you think you're fat? You're underweight. Here — look in the mirror." D. "You really look terrible at this weight. I hope you'll eat."   5. A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response?  A. "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?" B. "It's your decision. If you don't want to go, you don't have to." C. "You seem upset about the meetings." D. "You have to go to the meetings. It's part of your treatment plan." 

  6. A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written:  A. abstractly. B. by the client alone. C. jointly by the client and nurse. D. jointly by the physician and nurse.   7. During which phase of alcoholism is loss of control and physiologic dependence evident?  A. Prealcoholic phase B. Early alcoholic phaseC. Crucial phase D. Chronic phase   8. Which of the following is important when restraining a violent client?  A. Have three staff members present, one for each side of the body and one for the head. B. Always tie restraints to side rails. C. Have an organized, efficient team approach after the decision is made to restrain the client. D. Secure restraints to the gurney with knots to prevent escape.   9. A client who's actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP?  A. Dilated pupils B. Nystagmus C. Paranoia D. Altered mood   10. A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?  A. Initiating caloric and nutritional therapy as ordered B. Instituting behavioral modification therapy as ordered C. Addressing the client's low self-esteem D. Regularly monitoring vital signs and weight 

  11. A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations?  A. A no-suicide contract B. Weekly outpatient therapy C. A second psychiatric opinion D. Intensive inpatient treatment   12. Which of the following etiologic factors predispose a client to Tourette syndrome?  A. No known etiology B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics C. Abnormalities in the structure and function of the ventricles D. Environmental factors and birth-related trauma  13. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?  A. Withdrawal B. Logical thinking C. Repression D. Denial   14. An 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:  A. violence on television. B. passive parents. C. an internal locus of control. D. a single-parent family   15. A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands that:  A. open boundaries are common in violent families. B. violence usually results from a power struggle. C. domestic violence and abuse span all socioeconomic classes. D. violent behavior is a genetic trait passed from one generation to the next.   16. On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to:  

A. avoid all products containing alcohol. B. adhere to concomitant vitamin B therapy. C. return for monthly blood drug level monitoring. D. limit alcohol consumption to a moderate level.   17. During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response?  A. "That's it! You're on suicide precautions." B. "I'm going to tell your physician. Do you want to tell me why you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection." D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."   18. The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:  A. barbiturates. B. amphetamines. C. methadone. D. benzodiazepines. 

19. The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:  A. dilated pupils and slurred speech. B. rapid speech and agitation. C. dilated pupils and agitation. D. euphoria and constricted pupils.  20. Which of the following signs should the nurse expect in a client with known amphetamine overdose?  A. Hypotension B. Tachycardia C. Hot, dry skin D. Constricted pupils   21. A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the

first priority?  A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode   22. Which nursing action is best when trying to diffuse a client's impending violent behavior?  A. Helping the client identify and express feelings of anxiety and anger B. Involving the client in a quiet activity to divert attention C. Leaving the client alone until the client can talk about feelings D. Placing the client in seclusion   23. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?  A. Abstinence is the basis for successful treatment. B. Attendance at Alcoholics Anonymous meetings every day will cure alcoholism. C. For treatment to be successful, family members must participate. D. An occasional social drink is acceptable behavior for the alcoholic   24. Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder?  A. An overbearing mother B. Rejection by peers C. A history of schizophrenia in the family D. Low socioeconomic status   25. In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using?  A. Denial B. Obsession C. Compensation D. Rationalization   26. A client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, the nurse expects the physician to

prescribe:  A. lidocaine (Xylocaine). B. procainamide (Pronestyl). C. nitroglycerin (Nitro-Bid IV). D. epinephrine.  27. A 15-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. The nurse conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?  A. "I like the way I look. I just need to keep my weight down because I'm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."   28. Which is the drug of choice for treating Tourette syndrome?  A. fluoxetine (Prozac) B. fluvoxamine (Luvox) C. haloperidol (Haldol) D. paroxetine (Paxil)  29. The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?

A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."   30. A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?  A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness   31. When monitoring a client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse

expects the physician to prescribe:  A. norepinephrine (Levophed) and lidocaine (Xylocaine). B. nifedipine (Procardia) and lidocaine. C. nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc). D. nifedipine and esmolol  32. A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority?  A. The client will commit to a drug-free lifestyle. B. The client will work with the nurse to remain safe. C. The client will drink plenty of fluids daily. D. The client will make a personal inventory of strengths  33. A client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues?  A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hypervigilance and talk of past violent acts   34. A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."   35. A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of:  A. Ineffective individual coping related to feelings of guilt. B. Situational low self-esteem related to feelings of loss of control. C. Risk for violence: Self-directed related to impulsive mutilating acts. D. Risk for violence: Directed toward others related to verbal threats. 

 36. A client recently admitted to the hospital with sharp, substernal

chest pain suddenly complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use?  A. Coronary artery spasmB. Bradyarrhythmias C. Neurobehavioral deficits D. Panic disorder   37. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to:  A. begin after 7 days. B. not occur at all because the time period for their occurrence has passed. C. begin anytime within the next 1 to 2 days. D. begin within 2 to 7 days.  38. The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client?  A. Providing one-on-one supervision during meals and for 1 hour afterward B. Letting the client eat with other clients to create a normal mealtime atmosphere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired   39. A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time?  A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes  40. Which assessment finding is most consistent with early alcohol withdrawal?  A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute 

C. Blood pressure of 100/70 mm Hg D. Blood pressure of 140/80 mm Hg   41. Which client is at highest risk for suicide? 

A. One who appears depressed, frequently thinks of dying, and gives away all personal possessions B. One who plans a violent death and has the means readily available C. One who tells others that he or she might do something if life doesn't get better soon D. One who talks about wanting to die   42. Which of the following medical conditions is commonly found in clients with bulimia nervosa?  A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A  43. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?  A. The student discusses conflicts over drug use. B. The student accepts a referral to a substance abuse counselor. C. The student agrees to inform his parents of the problem. D. The student reports increased comfort with making choices.  44. A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the physician is most likely to prescribe which drug? 

A. clozapine (Clozaril) B. thiothixene (Navane) C. lorazepam (Ativan) D. lithium carbonate (Eskalith)   45. A client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join which organization?  A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous   46. A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse

should plan to:  A. severely restrict the client's physical activities. B. weigh the client daily, after the evening meal. C. monitor vital signs, serum electrolyte levels, and acid-base balance. D. instruct the client to keep an accurate record of food and fluid intake.   47. A young man is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:  A. antisocial personality disorder. B. borderline personality disorder. C. obsessive-compulsive personality disorder. D. narcissistic personality disorder.   48. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband:  A. has only moderate impulse control. B. denies feelings of jealousy or possessiveness. C. has learned violence as an acceptable behavior. D. feels secure in his relationship with his wife.   49. A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to:  A. manipulate her husband. B. gain control of one part of her life. C. commit suicide. D. live up to her mother's expectations.   50. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:  A. psychotherapy. B. total abstinence. C. Alcoholics Anonymous (AA). D. aversion therapy. 

PART 8 ANSWERS

1. C. Lack of self-esteem, strong dependency needs, and impulsive behavior Rationale: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also is common. Typically, the client can't tolerate being alone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent  2.C. Several small, dime-sized circular burns on the child's back Rationale: Small circular burns on a child's back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group.  3.B. anorexia nervosa. Rationale: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client is hypotensive and dehydrated. Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may be accompanied by weight loss, it isn't characterized by a body image disturbance or the intense fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre eating patterns, but it rarely causes the full syndrome of anorexia nervosa.  4. B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable." Rationale: Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse is informing her of her treatment options. Option A doesn't tell the client about the consequences of choosing not to eat. Telling clients that they are too thin won't change their self-image.  5. C. "You seem upset about the meetings." Rationale: The substance abuser uses the substance to cope with feelings and may deny the abuse. Asking if the client is upset about the meetings encourages the client to identify and deal with feelings instead of covering them up. Arguing with the client about the substance abuse (option A) or insisting that the client attend the meetings (option D) wouldn't help the client identify resistance to

treatment. Option B isn't therapeutic behavior because it plays down the importance of attending meetings.  6. C. jointly by the client and nurse. Rationale: A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior. The most effective contract — and the type least likely to allow for manipulation and misinterpretation — states the behavioral terms as concretely as possible. A contract written solely by the client may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client.  7. C. Crucial phase Rationale: The crucial phase is marked by physical dependence. The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration.  8. C. Have an organized, efficient team approach after the decision is made to restrain the client. Rationale: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots  9. B. Nystagmus Rationale: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus and ataxia are common physical findings of PCP use. Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood occur with both PCP and LSD ingestion.  10. A. Initiating caloric and nutritional therapy as ordered Rationale: The client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychoanalysis (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival  11. D. Intensive inpatient treatment 

Rationale: Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-suicide contract is an important strategy, but this client requires additional care. Weekly therapy wouldn't provide the intensity of care that this case warrants. Obtaining a second opinion would take time; this client requires immediate intervention.  12. B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics Rationale: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucleus. The ventricles in the brain, environmental factors, and birth trauma aren't involved.  13. D. Denial Rationale: Denial is an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking IS the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.  14. A. violence on television. Rationale: Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence.  15. C. domestic violence and abuse span all socioeconomic classes. Rationale: Domestic violence and abuse affect all socioeconomic classes. Closed boundaries and an imbalance of power, with one member having control over the others, are common in violent families. Although violent behavior may be passed from one generation to the next, it's a learned behavior, not a genetic trait.  16. A. avoid all products containing alcohol. Rationale: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy and blood monitoring aren't necessary during disulfiram therapy.  17. D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." Rationale: This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. Options A and B

put the client on the defensive and may lead to a power struggle. Option C ignores the psychological implications of the client's actions.  18. C. methadone. Rationale: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.  19. D. euphoria and constricted pupils. Rationale: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.  20. B. Tachycardia Rationale: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.  21. A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output Rationale: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care. Fluids are typically increased unless contraindicated by a preexisting medical condition.   22. A. Helping the client identify and express feelings of anxiety and anger Rationale: In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as "What happened to get you this angry?" may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of the client acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and provides a feeling of security.  23. A. Abstinence is the basis for successful treatment. 

Rationale: The foundation of any treatment for alcoholism is abstinence. Attendance at Alcoholics Anonymous is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking.  24. B. Rejection by peers Rationale: Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Aggression and conduct disorder are represented in all socioeconomic groups. Schizophrenia and an overbearing mother haven't been associated with aggression or conduct disorder  25. A. Denial Rationale: A client who states that he or she doesn't have a drug problem and can quit using drugs at any time — despite evidence to the contrary — is denying the drug addiction. Obsession isn't a defense mechanism. In compensation, the client emphasizes positive attributes to compensate for negative ones. In rationalization, the client justifies behaviors by faulty logic.  26. C. nitroglycerin (Nitro-Bid IV). Rationale: The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is mostlikely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or asystole, the physician may prescribe epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects.  27. C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Rationale: Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be overweight when she looks in the mirror. Preferring fast food over healthy food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in a client with anorexia nervosa.  28. C. haloperidol (Haldol) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome 

 29. B. "Tell me how you feel about the accident." Rationale: An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency.  30. D. Diaphoresis, tremors, and nervousness Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.  31. D. nifedipine and esmolol Rationale: This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an antiarrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension.  32. B. The client will work with the nurse to remain safe. Rationale: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.  33. A. A rigid posture, restlessness, and glaring Rationale: Behavioral clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance. 

 34. D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." Rationale: According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A), increased time and money spent on the substance (option B), inability to fulfill role obligations (option C), and typical withdrawal symptoms.  35. C. Risk for violence: Self-directed related to impulsive mutilating acts. Rationale: The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.  36.A. Coronary artery spasmRationale: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, they are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not panic disorder.  37. C. begin anytime within the next 1 to 2 days. Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.  38. A. Providing one-on-one supervision during meals and for 1 hour afterward Rationale: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat and give attention for not eating. Option C would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat, as in option D, the nurse should set limits and let the client know what is expected. 

 39. C. Providing a quiet environment and administering medication as needed and prescribed Rationale: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.  40. A. Heart rate of 120 to 140 beats/minute Rationale: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.  41. B. One who plans a violent death and has the means readily available Rationale: The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). A client who gives away possessions, thinks about death, or talks about wanting to die or attempting suicide is considered at a lower risk for suicide because this behavior typically serves to alert others that the client is contemplating suicide and wishes to be helped.  42. C. Diabetes mellitus Rationale: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A.  43. B. The student accepts a referral to a substance abuse counselor. Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.  44. C. lorazepam (Ativan) Rationale: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and

thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.  45. A. Al-Anon Rationale: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve-step program.  46. C. monitor vital signs, serum electrolyte levels, and acid-base balance. Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately.  47. A. antisocial personality disorder. Rationale: The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.  48. C. has learned violence as an acceptable behavior. Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships.  49. B. gain control of one part of her life. Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control. This eating disorder doesn't represent an 

attempt to manipulate others or live up to their expectations (although anorexia nervosa has a high incidence in families that emphasize achievement). The client isn't attempting to commit suicide through starvation; rather, by refusing to eat, she is expressing feelings of despair, worthlessness, and hopelessness.  50. B. total abstinence. Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.

PART 9

1. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect?  A. Seizures B. Shivering C. Anxiety D. Chest pain  2. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:  A. avoid shopping for large amounts of food. B. control eating impulses. C. identify anxiety-causing situations. D. eat only three meals per day.   3. A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should:  A. check the client frequently at irregular intervals throughout the night. B. assure the client that the nurse will hold in confidence anything the client says. C. repeatedly discuss previous suicide attempts with the client. D. disregard decreased communication by the client because this is common in suicidal clients.  4. Which of the following drugs should the nurse prepare to administer to a client with a toxic acetaminophen (Tylenol) level?  A. deferoxamine mesylate (Desferal) B. succimer (Chemet) C. flumazenil (Romazicon) D. acetylcysteine (Mucomyst)   5. A client is admitted to the substance abuse unit for alcohol

detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal?  A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium)  6. During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?  A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."  7. A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response?  A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"  8. For a client with anorexia nervosa, which goal takes the highest priority?  A. The client will establish adequate daily nutritional intake. B. The client will make a contract with the nurse that sets a target weight. C. The client will identify self-perceptions about body size as unrealistic. D. The client will verbalize the possible physiological consequences of self-starvation.   9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem?  A. The injury isn't consistent with the history or the child's age. B. The mother and father tell different stories regarding what happened. C. The family is poor. D. The parents are argumentative and demanding with emergency department personnel. 

  10. For a client with anorexia nervosa, the nurse plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa?  A. They tend to overprotect their children. B. They usually have a history of substance abuse. C. They maintain emotional distance from their children. D. They alternate between loving and rejecting their children.   11. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene?  A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry   12. The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? 

A. Fill out the client's menu and make sure she eats at least half of what is on her tray. B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal. C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal. D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count.   13. The nurse is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority?  A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergyperson to discuss the moral implications of suicide   14. A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings?  

A. Avoid discussing the client's perceptions and feelings. B. Focus discussions on food and weight. C. Avoid discussing unrealistic cultural standards regarding weight. D. Provide objective data and feedback regarding the client's weight and attractiveness.   15. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?  A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese   16. The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?  A. Restrict visits with the family until the client begins to eat. B. Provide privacy during meals. C. Set up a strict eating plan for the client. D. Encourage the client to exercise, which will reduce her anxiety.  17. Victims of domestic violence should be assessed for what important information?  A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization   18. A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from:  A. acetate accumulation. B. thiamine deficiency. C. triglyceride buildup. D. a below-normal serum potassium level   19. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?

A. The child cries uncontrollably throughout the examination. B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined. D. The child doesn't make eye contact with the nurse.   20. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority?  A. Client's physical needs B. Client's safety needs C. Client's psychosocial needs D. Client's medical needs   21. Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?  A. Accept responsibility for own behaviors. B. Be able to verbalize own needs and assert rights. C. Set firm and consistent limits with the client. D. Allow the child to establish his own limits and boundaries.   22. A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse approach her initially? 

A. Enter the room quietly and move beside her to assess her injuries. B. Call for staff back-up before entering the room and restraining her. C. Move as much glass away from her as possible and sit next to her quietly. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.   23. A client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8" (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the plan of care?  A. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy   24. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital

signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect: 

A. a postoperative infection. B. alcohol withdrawal. C. acute sepsis. D. pneumonia.   25. Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of the following conditions might the drug be administered?  A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal   26. One of the goals for a client with anorexia nervosa is that the client will demonstrate increased individual coping by responding to stress in constructive ways. Which of the following actions is the best indicator that the client is working toward meeting the goal?  A. The client drinks 4 L of fluid per day. B. The client paces around the unit most of the day. C. The client keeps a journal and discusses it with the nurse. D. The client talks almost constantly with friends by telephone.  27. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:  A. "You must first stop drinking." B. "Your physician must refer you to this program." C. "Admit you're powerless over alcohol and that you need help." D. "You must bring along a friend who will support you."  28. An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism?  A. Regression B. Projection C. Reaction-formation D. Intellectualization   29. After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which

remark by the client indicates a realistic view of the future?  A. "I'm never going to use crack again." B. "I know what I have to do. I have to limit my crack use." C. "I'm going to take 1 day at a time. I'm not making any promises." D. "I will substitue crack for something else"   30. The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to:  A. accurately describe the amount consumed. B. underestimate the amount consumed. C. overestimate the amount consumed. D. deny any consumption of alcohol.   31. The nurse is assessing a 15-year-old female who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?  A. Tachycardia B. Warm, flushed extremities C. Parotid gland tenderness D. Coarse hair growth   32. A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is:  A. impending coma. B. manipulating behavior. C. suppression. D. perceptual disorders.   33. The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?  A. Wearing tight-fitting clothing B. Increased blood pressure C. Oily skin D. Excessive and ritualized exercise  34. A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals?  A. Alcohol withdrawal B. Cannibis withdrawal 

C. Cocaine withdrawal D. Opioid withdrawal  

35. A client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. Although she is 5′ 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), she talks incessantly about how fat she is. Which measure should the nurse take first when caring for this client?  A. Teach the client about nutrition, calories, and a balanced diet. B. Establish a trusting relationship with the client.  C. Discuss cultural stereotypes regarding thinness and attractiveness. D. Explore the reasons why the client doesn't eat.   36. A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:  A. tension and irritability. B. slow pulse. C. hypotension. D. constipation.  37. Which of the following drugs may be abused because of tolerance and physiologic dependence.  A. lithium (Lithobid) and divalproex (Depakote). B. verapamil (Calan) and chlorpromazine (Thorazine) C. alprazolam (Xanax) and phenobarbital (Luminal) D. clozapine (Clozaril) and amitriptyline (Elavil)   38. Which of the following groups are considered to be at highest risk for suicide?  A. Adolescents, men over age 45, and persons who have made previous suicide attempts B. Teachers, divorced persons, and substance abusers C. Alcohol abusers, widows, and young married men D. Depressed persons, physicians, and persons living in rural areas   39. Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as:  A. echolalia. B. palilalia. C. apraxia. D. aphonia.  40. A client is admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects the assessment to 

reveal:  A. unpredictable behavior and intense interpersonal relationships. B. inability to function as a responsible parent. C. somatic symptoms. D. coldness, detachment, and lack of tender feelings.  41. A client with disorganized type schizophrenia has been hospitalized for the past 2 years on a unit for chronic mentally ill clients. The client's behavior is labile and fluctuates from childishness and incoherence to loud yelling to slow but appropriate interaction. The client needs assistance with all activities of daily living. Which behavior is characteristic of disorganized type schizophrenia?  A. Extreme social impairment B. Suspicious delusions C. Waxy flexibility D. Elevated affect   42. The nurse is providing care for a female client with a history of schizophrenia who's experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What is the nurse's best action?  A. Administer the haloperidol orally if the client agrees to take it. B. Call the physician to clarify whether the haloperidol should be given orally or I.M. C. Call the physician to clarify the order because the dosage is too high. D. Withhold haloperidol because it may worsen hallucinations.  43. A client receiving haloperidol (Haldol) complains of a stiff jaw and difficulty swallowing. The nurse's first action is to:  A. reassure the client and administer as needed lorazepam (Ativan) I.M. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered. C. administer as needed dose of benztropine (Cogentin) by mouth as ordered. D. administer as needed dose of haloperidol (Haldol) by mouth.   44. A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him agitated. The nurse's best response at this time would be to:  A. take the client's vital signs. B. explore the content of the hallucinations. C. tell him his fear is unrealistic. D. engage the client in reality-oriented activities. 

  45. Which medication can control the extrapyramidal effects associated with antipsychotic agents?  A. perphenazine (Trilafon) B. doxepin (Sinequan) C. amantadine (Symmetrel) D. clorazepate (Tranxene)   46. A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. One approach that has proven to be effective for hallucinating clients is to:  A. take an as-needed dose of psychotropic medication whenever they hear voices. B. practice saying "Go away" or "Stop" when they hear voices. C. sing loudly to drown out the voices and provide a distraction. D. go to their room until the voices go away.   47. A dystonic reaction can be caused by which of the following medications?  A. diazepam (Valium) B. haloperidol (Haldol) C. amitriptyline (Elavil) D. clonazepam (Klonopin)  48. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process?  A. "I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics." B. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." C. "I'm not poisoning you. And how could I possibly steal your soul?" D. "I sense anger. Are you feeling angry today?"  49. A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?  A. "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you." B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." C. "You're wrong. Nobody is trying to kill you." 

D. "A foreign government is trying to kill you? Please tell me more about it." 

PART 9 ANSWERS

1. A. Seizures Rationale: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.  2. C. identify anxiety-causing situations. Rationale: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.  3. A. check the client frequently at irregular intervals throughout the night. Rationale: Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option B may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it (option D  4.D. acetylcysteine (Mucomyst) Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines.  5. D. chlordiazepoxide (Librium) Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal. 

6. D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." Rationale: This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.  7. B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote self-disclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior.  8. A. The client will establish adequate daily nutritional intake. Rationale: According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potential complications (as in option D).  9. A. The injury isn't consistent with the history or the child's age. Rationale: When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child.  10.A. They tend to overprotect their children. Rationale: Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. The characteristics described in options B, C, and D aren't typical of parents of children

with anorexia.  11. B. Calling a security guard and another staff member for assistance Rationale: The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, the health care worker should inform the husband what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives. Telling the husband to leave would probably be ineffective because of his agitated and irrational state. Exploring his anger doesn't take precedence over safeguarding the client and staff.

12. C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal. Rationale: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department.  13. B. Exploring the nurse's own feelings about suicide Rationale: The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn't a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may increase the client's trust or alleviate guilt; however, it isn't the highest priority.  14. D. Provide objective data and feedback regarding the client's weight and attractiveness. Rationale: By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the client's perceptions and feeling wouldn't help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the client establish more realistic weight goals.  15. B. Aftershave lotion 

Rationale: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client.  16. C. Set up a strict eating plan for the client. Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised. 

17. B. Readiness to leave the perpetrator and knowledge of resources Rationale: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships.  18.B. thiamine deficiency. Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms.  19. C. The child doesn't cry when the shoulder is examined. Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers.  20. B. Client's safety needs Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs have been met, the client's physical, psychosocial,

and medical needs can be met.  21. A. Accept responsibility for own behaviors. Rationale: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Options C and D aren't outcome criteria but interventions. Option B is incorrect as the oppositional child usually focuses on his own needs.  22. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her. Rationale: Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the client's response carefully. If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine injuries without first announcing the nurse's presence and assessing the dangers of the situation.  23. D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy Rationale: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health. Instead of protecting the client's health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.  24. B. alcohol withdrawal. Rationale: The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.  25. C. Opiate withdrawal Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain, such as fluoxotine (Prozac), are used to treat cocaine withdrawal.  26.C. The client keeps a journal and discusses it with the nurse. 

Rationale: The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress. Although physical activity can reduce stress, the anorexic client is more likely to use pacing to burn calories and lose weight. Although talks with friends can decrease stress, constant talking is more likely a way of avoiding dealing with problems. Increased fluid intake may be an attempt by the client to curb her appetite and artificially increase her weight. 

27. C. "Admit you're powerless over alcohol and that you need help." Rationale: The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. A physician referral isn't necessary to join. New members are assigned a support person who may be called upon when the client has the urge to drink.  28. A. Regression Rationale: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source. In reaction formation, the client acts in opposition to his feelings. In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.  29. C. "I'm going to take 1 day at a time. I'm not making any promises." Rationale: Twelve-step programs focus on recovery 1 day at a time.Such programs discourage people from claiming that they will never again use a substance, because relapse is common. The belief that one may use a limited amount of an abused substance indicates denial. Substituting one abused substance for another predisposes the client to cross-addiction.  30. B. underestimate the amount consumed. Rationale: Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves. Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.  31. C. Parotid gland tenderness Rationale: Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.  

32. D. perceptual disorders. Rationale: Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal. Coma isn't an immediate consequence. Manipulative behaviors are part of the alcoholic client's personality but aren't signs of alcohol withdrawal. Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.  33.D. Excessive and ritualized exercise Rationale: A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nails become dry and brittle and blood pressure and body temperature drop from excessive weight loss.  34. D. Opioid withdrawal Rationale: The symptoms listed are specific to opioid withdrawal. Alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannibis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.  35. B. Establish a trusting relationship with the client.  Rationale: A client with an eating disorder may be secretive and unwilling to admit that a problem exists. Therefore, the nurse first must establish a trusting relationship to elicit the client's feelings and thoughts. The anorexic client may spend long hours discussing nutrition or handling and preparing food in an effort to stall or avoid eating food; the nurse shouldn't reinforce her preoccupation with food, as in option A. Although cultural stereotypes may play a prominent role in anorexia nervosa, discussing these factors isn't the first action the nurse should take. Exploring the reasons why the client doesn't eat would increase her emotional investment in food and eating.  36. A. tension and irritability. Rationale: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option D is incorrect.  37. C. alprazolam (Xanax) and phenobarbital (Luminal) Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as phenobarbital, are addictive, controlled substances. All the other drugs listed aren't addictive substances.  38. A. Adolescents, men over age 45, and persons who have made previous suicide attempts Rationale: Studies of those who commit suicide reveal the following high-risk groups: adolescents; men over age 45; persons who have

made previous suicide attempts; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than men, they typically choose less lethal means and therefore are less likely to succeed in their attempts.  39. B. palilalia. Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak  

40. A. unpredictable behavior and intense interpersonal relationships. Rationale: A client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. Interpersonal relationships may be intense and unstable and behavior may be inappropriate and impulsive. Although the client's impaired ability to form relationships may affect parenting skills, inability to function as a responsible parent is more typical of antisocial personality disorder. Somatic symptoms characterize avoidant personality disorder. Coldness, detachment, and lack of tender feelings typify schizoid and schizotypal personality disorders.  41. A. Extreme social impairment Rationale: Disorganized type schizophrenia (formerly called hebephrenia) is characterized by extreme social impairment, marked inappropriate affect, silliness, grimacing, posturing, and fragmented delusions and hallucinations. A client with a paranoid disorder typically exhibits suspicious delusions, such as a belief that evil forces are after him. Waxy flexibility, a condition in which the client's limbs remain fixed in uncomfortable positions for long periods, characterizes catatonic schizophrenia. Elevated affect is associated withschizoaffective disorder.  42. C. Call the physician to clarify the order because the dosage is too high. Rationale: The dosage is too high (normal dosage ranges from 5 to 10 mg daily). Options A and B may lead to an overdose. Option D is incorrect because haloperidol helps with symptoms of hallucinations.  43. B. administer as needed dose of benztropine (Cogentin) I.M. as ordered. Rationale: The client is most likely suffering from muscle rigidity due to haloperidol. I.M. benztropine should be administered to prevent asphyxia or aspiration. Lorazepam treats anxiety, not extrapyramidal effects. Another dose of haloperidol would increase the severity of the reaction.  

44. B. explore the content of the hallucinations. Rationale: Exploring the content of the hallucinations will help the nurse understand the client's perspective on the situation. The client shouldn't be touched, such as in taking vital signs, without telling him exactly what is going to happen. Debating with the client about his emotions isn't therapeutic. When the client is calm, engage him in reality-based activities.  45. C. amantadine (Symmetrel) Rationale: Amantadine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents used to control extrapyramidal reactions include benztropine mesylate (Cogentin), trihexyphenidyl (Artane), biperiden (Akineton), and diphenhydramine (Benadryl). Perphenazine is an antipsychotic agent; doxepin, an antidepressant; and chlorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they don't alleviate extrapyramidal reactions.  46. B. practice saying "Go away" or "Stop" when they hear voices. Rationale: Researchers have found that some clients can learn to control bothersome hallucinations by telling the voices to go away or stop. Taking an as needed dose of psychotropic medication whenever the voices arise may lead to overmedication and put the client at risk for adverse effects. Because the voices aren't likely to go away permanently, the client must learn to deal with the hallucinations without relying on drugs. Although distraction is helpful, singing loudly may upset other clients and would be socially unacceptable after the client is discharged. Hallucinations are most bothersome in a quiet environment when the client is alone, so sending the client to his room would increase, rather than decrease, the hallucinations.  47. B. haloperidol (Haldol) Rationale: Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Diazepam and clonazepam are benzodiazepines, and amitriptyline is a tricyclic antidepressant. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.  48. B. "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." Rationale: The nurse should directly orient a delusional client to reality, especially to place and person. Options A and C may encourage further delusions by denying poisoning and offering information related to the delusion. Validating the client's feelings, as in option D, occurs during a later stage in the therapeutic process. 

49. B. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." Rationale: Responses should focus on reality while acknowledging the client's feelings. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

PART 10

1. Which of the following is not one of the key steps in the grief process? 

A. Denial  B. Anger  C. Bargaining  D. Rejection  

2. Which of the following matches the definition: covering up a weakness by stressing a desirable or stronger trait?  

A. Compensation  B. Projection  C. Rationalization  D. Dysphoria  

3. Which of the following waveforms is most commonly found with light sleepers?  

A. Theta  B. Alpha  C. Beta  D. Zeta  

4. Which of the following months matches with an infant first having the ability to sit-up independently?  

A. 4 months  B. 6 months  C. 8 months  D. 10 months  

5. Object permanence for toddlers develops in this age range?  

A. 5-10 months  B. 10-14 months  

C. 12-24 months  D. 15-24 months  

6. Which of the following matches the definition: attributing of our own unwanted trait onto another person?  

A. Compensation  B. Projection  C. Rationalization  D. Dysphoria  

7. Which of the following matches the definition: the justification of behaviors using reason other than the real reason?  

A. Compensation  B. Projection  C. Rationalization  D. Dysphoria  

8. Which of the following matches the definition: response to severe emotion stress resulting in involuntary disturbance of physical functions?  

A. Conversion disorder  B. Depressive reaction  C. Bipolar disorder  D. Alzheimer's disease  

9. Which of the following waveforms is most commonly found when you are awake?  

A. Theta  B. Alpha  C. Beta  D. Zeta  

10. The REM sleep cycle occur approximately every ____ minutes?  

A. 45  B. 60  C. 75  D. 90  

11. Which of the following reflexes is not found at birth?  

A. Babinski  B. Palmar  

C. Moro  D. Flexion  

12. Parallel play for toddlers develops in this age range?  

A. 5-10 months  B. 10-14 months  C. 12-24 months  D. 24-48 months  

13. Which of the following is not a sign of anxiety?  

A. Dyspnea  B. Hyperventilation  C. Moist mouth  D. GI symptoms  

14. Which of the following best describes a person that is completely awake falling asleep spontaneously?  

A. Cataplexy  B. Narcolepsy  C. Transitional sleep  D. REM absence  

15. Which of the following best describes a person that is unable to tell you were there hand or foot is?  

A. Autotopagnosia  B. Cataplexy  C. Ergophobia  D. Anosognosia  

16. Which of the following is not a characteristic of a panic disorder?  

A. Nausea  B. Excessive perspiration  C. Urination  D. Chest pain  

17. Which of the following categories would a 70 year old adult be placed in?  

A. Intimacy vs. Isolation  B. Generativitiy vs. Stagnation  C. Integrity vs. Despair  D. Longevity vs. Guilt  

18. Which of the following categories would a 60 year old adult be placed in?  

A. Intimacy vs. Isolation  B. Generativitiy vs. Stagnation  C. Integrity vs. Despair  D. Longevity vs. Guilt  

19. Which of the following categories would a 20 year old adult be placed in?  

A. Intimacy vs. Isolation  B. Generativitiy vs. StagnationC. Integrity vs. Despair  D. Longevity vs. Guilt  

20. Which of the following describes a person using words that have no known meaning?  

A. Neologisms  B. Neolithic  C. Verbalism  D. Delusional blocking