Post by Nursing Board 101 on Aug 18, 2010 13:29:04 GMT -5
1. 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).
A. RATIONALE: Benztropine, trihexyphenidyl, or amantadine is prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.
2. The nurse is providing care for a female client with a history of schizophrenia who is experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What's 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.
C. 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.
3. The nurse is providing care to a client with 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.
C. 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.
4. 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.
B. 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/ml, 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.
5. 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
B. RATIONALE: Lithium is chemically similar to sodium. When sodium levels are reduced, such as from sweating or diuresis, lithium is reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions, but sodium is most important to the absorption of lithium.
6. 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."
B. 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.
7. 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, masklike face
d.)Extremity and neck spasms, facial grimacing, jerky movements
C. 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.
8. 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
D. RATIONALE: As antidepressants begin to take effect and the client feels better, she may have the energy to initiate and complete another suicide attempt. As the client's energy level increases, the nurse must continue to be vigilant to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics and aren't adverse effects of antidepressants. A therapeutic relationship should be initiated upon admission to the psychiatric unit, after suicide precautions have been instituted. It's through this relationship that the client develops feelings of self-worth and trust and problem-solving takes place. In a no-suicide contract, the client states verbally or in writing that she won't attempt suicide and will seek out staff if she has suicidal thoughts. When the time period for a contract has expired, a new contract should be obtained from the client.
9. 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
A. RATIONALE: Focusing on the client's blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own self-care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren't under the client's control and are real to him. Eye exercises won't resolve the client's blindness because no organic pathology is causing the symptoms.
10. 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.
B. RATIONALE: Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.
11. 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.
B. 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.
12. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous (AA) 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.
C. RATIONALE: The first of the Twelve Steps of AA is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although AA 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.
13. The nurse is assessing a 15-year-old female who is 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
C. 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.
14. The nurse is assessing an adult's developmental stage. The nurse should consider: a.)height and weight.
b.)blood pressure.
c.)previous problem-solving strategies.
d.)pulse rate.
C. RATIONALE: The nurse can use problem-solving strategies to assess an adult's developmental stage as it relates to intellectual functioning such as problem-solving. The other choices are related to physiological attributes.
15. 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
B. RATIONALE: Coping is a process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic, focusing on relieving the discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, previous coping skills is the best answer. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome.
16. 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
B. RATIONALE: The nurse's first responsibility is to protect the client from injuring himself. Listening and being nonjudgmental are important elements of the nurse's communication with the client. After the client's safety has been established, he would benefit from a referral to a mental health professional.
17. 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
D. 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.
18. 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.
B. 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.
19. 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.
C. RATIONALE: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It's important for the child to find a way to express internalized feelings. The child must also know that he isn't to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn't the main goal of therapy.
20. 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.
A. RATIONALE: The foundation of any treatment for alcoholism is abstinence. Attendance at AA 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.
21. A client exhibits the following defining characteristics: denial of problems that are evident to others, expressions of shame or guilt, perceptions of self as being unable to deal with events, and projection of blame or responsibility for problems onto others. How would a nurse diagnose this client?
a.)Anxiety
b.)Chronic low self-esteem
c.)Ineffective denial
d.)Ineffective individual coping
B. RATIONALE: The defining characteristics are those of chronic low self-esteem. The definition of this diagnosis is negative self-evaluation, along with negative feelings about self or capabilities, which may be directly or indirectly expressed. Anxiety, ineffective denial, and ineffective individual coping all have different sets of defining characteristics.
22. What herbal medication for depression, widely used in Europe, is now being introduced in the Philippines and in the United States?
a.)Ginkgo biloba
b.)Echinacea
c.)St. John's wort
d.)Ephedra
C. RATIONALE: St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. Ginkgo biloba is prescribed to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant, similar to ephedrine.
23. 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's 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 keep a strict calorie count.
C. 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 be allowed to eat food only provided by the dietary department.
24. 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.”
C. "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 to 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.
25. Which psychological or personality factors are most likely to predispose an individual to medication abuse?
a.)Low self-esteem and unresolved rage
b.)Desire to inflict pain upon oneself
c.)Obsessive-compulsive disorder
d.)Codependency
A. RATIONALE: Low self-esteem and repressed anger and rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. The final two options are psychological disorders not usually associated with medication abuse.
26. A client chronically complains of being unappreciated and misunderstood by others. She's argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which of the following personality disorders?
a.)Dependent personality
b.)Passive-aggressive personality
c.)Avoidant personality disorder
d.)Obsessive-compulsive disorder
B. RATIONALE: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. The client with a dependent personality is unable to make everyday decisions and allows others to make important decisions. In addition, the client with a dependent personality often volunteers to do things that are unpleasant so that others will like him. The obsessive-compulsive personality displays a pervasive pattern of perfectionism and inflexibility. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity.
27. A client diagnosed with depression tells the nurse, "I won't allow myself to cry because it upsets the whole family when I cry." This is an example of:
a.)manipulation.
b.)insight.
c.)rationalization.
d.)repression.
C. RATIONALE: Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable explanations. Insight is comprehension of one's own behavior, often followed by an attempt to change it. Repression is involuntary exclusion of painful and conflicting thoughts or feelings from awareness. Based on the information provided, the client doesn't seem to be manipulating those around her.
28. A client diagnosed with major depression has started taking amitriptyline (Elavil), a tricyclic antidepressant. What's a common adverse effect of this drug?
a.)Weight loss
b.)Dry mouth
c.)Increased blood pressure
d.)Muscle spasms
B. RATIONALE: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain & not loss & is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants.
29. A client has received treatment for depression for 3 weeks. Which behavior suggests that the client is recovering from depression?
a.)The client talks about the difficulties of returning to college after discharge.
b.)The client spends most of the day sitting alone in the corner of the room.
c.)The client wears a hospital gown instead of street clothes.
d.)The client shows no emotion when visitors leave.
A. RATIONALE: By talking about returning to college, the client is demonstrating an interest in making plans for the future, which is a sign of recovery from depression. Decreased socialization, lack of interest in personal appearance, and lack of emotion are all symptoms of depression.
30. A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?
a.)Ask other clients and staff members to ignore the client's behavior.
b.)Set limits with consequences for belittling or demanding behavior.
c.)Offer the client an antianxiety drug when belittling or demanding behavior occurs.
d.)Offer the client a variety of stimulating activities to distract him from belittling or making demands of others.
B. RATIONALE: To protect others from a client who exhibits belittling and demanding behaviors, the nurse may need to set limits with consequences for noncompliance. Asking others to ignore the client is likely to increase those behaviors. Offering the client an antianxiety drug or stimulating activities provides no motivation for the client to change problematic behaviors.
a.)benztropine (Cogentin).
b.)diphenhydramine (Benadryl).
c.)propranolol (Inderal).
d.)haloperidol (Haldol).
A. RATIONALE: Benztropine, trihexyphenidyl, or amantadine is prescribed for a client with Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.
2. The nurse is providing care for a female client with a history of schizophrenia who is experiencing hallucinations. The physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What's 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.
C. 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.
3. The nurse is providing care to a client with 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.
C. 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.
4. 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.
B. 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/ml, 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.
5. 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
B. RATIONALE: Lithium is chemically similar to sodium. When sodium levels are reduced, such as from sweating or diuresis, lithium is reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn't restrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions, but sodium is most important to the absorption of lithium.
6. 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."
B. 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.
7. 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, masklike face
d.)Extremity and neck spasms, facial grimacing, jerky movements
C. 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.
8. 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
D. RATIONALE: As antidepressants begin to take effect and the client feels better, she may have the energy to initiate and complete another suicide attempt. As the client's energy level increases, the nurse must continue to be vigilant to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics and aren't adverse effects of antidepressants. A therapeutic relationship should be initiated upon admission to the psychiatric unit, after suicide precautions have been instituted. It's through this relationship that the client develops feelings of self-worth and trust and problem-solving takes place. In a no-suicide contract, the client states verbally or in writing that she won't attempt suicide and will seek out staff if she has suicidal thoughts. When the time period for a contract has expired, a new contract should be obtained from the client.
9. 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
A. RATIONALE: Focusing on the client's blindness can positively reinforce the blindness and further promote the use of maladaptive behaviors to obtain secondary gains. The client should be encouraged to participate in his own self-care as much as possible to avoid fostering dependency. To promote self-esteem, give positive reinforcement for what the client can do. Blindness and other physical symptoms in a conversion disorder aren't under the client's control and are real to him. Eye exercises won't resolve the client's blindness because no organic pathology is causing the symptoms.
10. 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.
B. RATIONALE: Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting behaviors and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.
11. 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.
B. 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.
12. The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous (AA) 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.
C. RATIONALE: The first of the Twelve Steps of AA is admitting that an individual is powerless over alcohol and that life has become unmanageable. Although AA 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.
13. The nurse is assessing a 15-year-old female who is 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
C. 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.
14. The nurse is assessing an adult's developmental stage. The nurse should consider: a.)height and weight.
b.)blood pressure.
c.)previous problem-solving strategies.
d.)pulse rate.
C. RATIONALE: The nurse can use problem-solving strategies to assess an adult's developmental stage as it relates to intellectual functioning such as problem-solving. The other choices are related to physiological attributes.
15. 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
B. RATIONALE: Coping is a process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic, focusing on relieving the discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, previous coping skills is the best answer. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome.
16. 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
B. RATIONALE: The nurse's first responsibility is to protect the client from injuring himself. Listening and being nonjudgmental are important elements of the nurse's communication with the client. After the client's safety has been established, he would benefit from a referral to a mental health professional.
17. 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
D. 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.
18. 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.
B. 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.
19. 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.
C. RATIONALE: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. It's important for the child to find a way to express internalized feelings. The child must also know that he isn't to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn't the main goal of therapy.
20. 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.
A. RATIONALE: The foundation of any treatment for alcoholism is abstinence. Attendance at AA 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.
21. A client exhibits the following defining characteristics: denial of problems that are evident to others, expressions of shame or guilt, perceptions of self as being unable to deal with events, and projection of blame or responsibility for problems onto others. How would a nurse diagnose this client?
a.)Anxiety
b.)Chronic low self-esteem
c.)Ineffective denial
d.)Ineffective individual coping
B. RATIONALE: The defining characteristics are those of chronic low self-esteem. The definition of this diagnosis is negative self-evaluation, along with negative feelings about self or capabilities, which may be directly or indirectly expressed. Anxiety, ineffective denial, and ineffective individual coping all have different sets of defining characteristics.
22. What herbal medication for depression, widely used in Europe, is now being introduced in the Philippines and in the United States?
a.)Ginkgo biloba
b.)Echinacea
c.)St. John's wort
d.)Ephedra
C. RATIONALE: St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants. Ginkgo biloba is prescribed to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant, similar to ephedrine.
23. 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's 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 keep a strict calorie count.
C. 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 be allowed to eat food only provided by the dietary department.
24. 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.”
C. "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 to 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.
25. Which psychological or personality factors are most likely to predispose an individual to medication abuse?
a.)Low self-esteem and unresolved rage
b.)Desire to inflict pain upon oneself
c.)Obsessive-compulsive disorder
d.)Codependency
A. RATIONALE: Low self-esteem and repressed anger and rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. The final two options are psychological disorders not usually associated with medication abuse.
26. A client chronically complains of being unappreciated and misunderstood by others. She's argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which of the following personality disorders?
a.)Dependent personality
b.)Passive-aggressive personality
c.)Avoidant personality disorder
d.)Obsessive-compulsive disorder
B. RATIONALE: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. The client with a dependent personality is unable to make everyday decisions and allows others to make important decisions. In addition, the client with a dependent personality often volunteers to do things that are unpleasant so that others will like him. The obsessive-compulsive personality displays a pervasive pattern of perfectionism and inflexibility. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity.
27. A client diagnosed with depression tells the nurse, "I won't allow myself to cry because it upsets the whole family when I cry." This is an example of:
a.)manipulation.
b.)insight.
c.)rationalization.
d.)repression.
C. RATIONALE: Rationalization is a defense mechanism used to justify actions or feelings with seemingly reasonable explanations. Insight is comprehension of one's own behavior, often followed by an attempt to change it. Repression is involuntary exclusion of painful and conflicting thoughts or feelings from awareness. Based on the information provided, the client doesn't seem to be manipulating those around her.
28. A client diagnosed with major depression has started taking amitriptyline (Elavil), a tricyclic antidepressant. What's a common adverse effect of this drug?
a.)Weight loss
b.)Dry mouth
c.)Increased blood pressure
d.)Muscle spasms
B. RATIONALE: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain & not loss & is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants.
29. A client has received treatment for depression for 3 weeks. Which behavior suggests that the client is recovering from depression?
a.)The client talks about the difficulties of returning to college after discharge.
b.)The client spends most of the day sitting alone in the corner of the room.
c.)The client wears a hospital gown instead of street clothes.
d.)The client shows no emotion when visitors leave.
A. RATIONALE: By talking about returning to college, the client is demonstrating an interest in making plans for the future, which is a sign of recovery from depression. Decreased socialization, lack of interest in personal appearance, and lack of emotion are all symptoms of depression.
30. A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?
a.)Ask other clients and staff members to ignore the client's behavior.
b.)Set limits with consequences for belittling or demanding behavior.
c.)Offer the client an antianxiety drug when belittling or demanding behavior occurs.
d.)Offer the client a variety of stimulating activities to distract him from belittling or making demands of others.
B. RATIONALE: To protect others from a client who exhibits belittling and demanding behaviors, the nurse may need to set limits with consequences for noncompliance. Asking others to ignore the client is likely to increase those behaviors. Offering the client an antianxiety drug or stimulating activities provides no motivation for the client to change problematic behaviors.