Exam 2

Question 1

The effects of stress can be seen by measurement of clinical changes of the body. This statement is a tenet of which theorist?

Answer 1

Selye

Question 2

When an individual experiences stress, increased activity of the noradrenergic and dopaminergic systems results. The nurse should assess for:

Answer 2

hyperarousal and hypervigilance

Question 3

If a patient’s threshold set point for anxiety is lowered, the nurse can expect subsequent stressors to:

Answer 3

easily reactivate the anxiety response.

Question 4

Nursing interventions for a patient experiencing anxiety at a moderate level or greater are based on:

Answer 4

relief behaviors the patient is using.

Question 5

A nurse assesses a patient facing possible unemployment. The patient has been anxious for several days and says, “I can’t stop thinking about the financial ruin I face. I’ve never been this worried. I don’t know what to do.” The patient’s coping is:

Answer 5

maladaptive.

Question 6

A teenager has been promiscuous and is experiencing anxiety because her menses is late. Last night, she temporarily dismissed this concern by going to a concert with friends. Today she is anxious again and comes to the clinic. The patient’s coping is:

Answer 6

palliative.

Question 7

A patient visiting the crisis clinic for the first time asks, “How long will I be coming here?” The nurse’s reply should consider that the usual duration of a crisis situation seldom exceeds:

Answer 7

4 to 6 weeks.

Question 8

A 75-year-old patient with a long history of depression begins amitryptiline (Elavil) 100 mg/day. The patient also takes a diuretic daily for hypertension. The highest priority nursing diagnosis is risk for:

Answer 8

falls related to dizziness and orthostatic hypotension.

Question 9

A patient with depression has taken an SSRI for 1 month. The nurse should use direct questions to evaluate which potential side effect?

Answer 9

Sexual dysfunction

Question 10

The nurse cares for four patients receiving SSRIs. Which assessment finding warrants the nurse’s priority attention?

Answer 10

Confusion, agitation, and hyperthermia

Question 11

A patient who takes an SSRI reports, “I started taking St. John’s wort to boost the effects of my anti-depressant.” The nurse should advise the patient, “The herb:

Answer 11

may interact with the SSRI to cause a life-threatening reaction.”

Question 12

To help a patient cope with orthostatic hypotension caused by antidepressant medication, the nurse should advise the patient to:

Answer 12

rise slowly and to sit before standing.

Question 13

The nurse’s priority assessment for an adolescent patient taking an SSRI antidepressant medication is for the presence of:

Answer 13

suicidal ideation.

Question 14

A patient receiving a traditional high-potency antipsychotic medication should be closely monitored for:

Answer 14

extrapyramidal side effects.

Question 15

A patient receives a traditional low-potency antipsychotic medication. The nurse should assess closely for:

Answer 15

urinary frequency.

Question 16

A patient is diagnosed with neuroleptic malignant syndrome. Which medication from the patient’s pharmacologic profile most likely led to this problem?

Answer 16

Haloperidol (Haldol)

Question 17

A patient who takes haloperidol (Haldol) 10 mg/day PO developed restlessness, agitation, and an inability to sit still. The nurse then administered a PRN dose of haloperidol 5 mg IM. One hour later, the patient’s symptoms were worse. What is the most likely explanation?

Answer 17

The patient was experiencing akathisia, which worsened after receiving the PRN medication.

Question 18

An adult with schizophrenia was started on clozapine (Clozaril) 4 days ago. At 2100 today, the patient’s vital signs are T 101° F; P 143; R 20; BP 100/60. What is the nurse’s best action regarding the 2100 dose of clozapine?

Answer 18

Hold the medication and notify the health care provider.

Question 19

A patient is being switched to clozapine (Clozaril) from therapy using a traditional antipsychotic. The patient asks, “What’s the advantage of the new drug?” Select the nurse’s best response.

Answer 19

“It is sometimes effective when other drugs fail.”

Question 20

A patient who takes a traditional antipsychotic medication says, “I feel shaky and very warm.” The patient is diaphoretic. The nurse should further assess for what complication?

Answer 20

Neuroleptic malignant syndrome (NMS)

Question 21

A patient who takes a traditional antipsychotic medication says, “I feel shaky and very warm.” The patient is diaphoretic. What is the nurse’s best first action?

Answer 21

Take the patient’s vital signs.

Question 22

A nurse cares for four patients with schizophrenia who are receiving antipsychotic medication. Which patient will receive the nurse’s priority attention? The patient:

Answer 22

with diaphoresis and a temperature of 104°F.

Question 23

Maintenance of a therapeutic serum level of lithium is dependent on adequate serum levels of:

Answer 23

sodium.

Question 24

For 2 weeks, a patient has taken lithium (Lithane) and risperidone (Risperdal) daily for mania. The patient now complains of diarrhea, vomiting, and blurred vision. The nurse observes a coarse hand tremor. Select the nurse’s priority action.

Answer 24

Hold the next dose of lithium, and obtain a stat lithium level.

Question 25

A patient with rapid cycling bipolar disorder is not responding to lithium therapy. At the next multidisciplinary team meeting, the nurse should point out that many rapid-cycling patients have been effectively treated using:

Answer 25

valproic acid (Depakene).

Question 26

A patient has taken lithium (Lithane) 600 mg t.i.d. for 1 week. A laboratory result in which range shows that the desired serum lithium level was achieved?

Answer 26

0.6 to 1.2 mEq/L

Question 27

The nurse scheduling the serum lithium level blood draw for a patient should arrange for it to be obtained:

Answer 27

before the first morning dose.

Question 28

A patient’s serum lithium level is 1.8 mEq/L. Select the nurse’s priority action.

Answer 28

Assess for signs of toxicity.

Question 29

Teaching for a patient who is to be discharged on a maintenance dose of lithium should emphasize the importance of:

Answer 29

keeping appointments for serum lithium level testing.

Question 30

-A nurse administers a highly protein-bound medication. Which patient would have the most immediate and powerful effect from this drug?

Answer 30

A 76-year-old patient with malnutrition

Question 31

A new nurse asks, “What is the role of psychopharmacology in the psychotherapeutic management model?” A mentor should respond that psychopharmacology makes it possible to:

Answer 31

identify desirable outcomes.

Question 32

A nurse administers a drug that is highly lipid-soluble. When should the nurse assess for expected effects of the drug?

Answer 32

30 minutes after administration.

Question 33

A nurse assesses a newly hospitalized patient with a long history of serious and persistent mental illness. The priority assessment information to obtain is:

Answer 33

length of time on various psychotropic medications.

Question 34

-A realistic outcome of patient teaching about psychotropic medication is that the patient will:

Answer 34

state the purpose, dose, and significant side effects of each drug prescribed.

Question 35

A week after beginning fluoxetine (Prozac), a patient complains, “I still feel so depressed all the time.” Based on pharmacodynamics, the nurse’s best action is to:

Answer 35

educate the patient that the drug needs more time to be effective.

Question 36

A nurse administering an SSRI antidepressant should carefully observe the patient for symptoms related to:

Answer 36

increased serotonin level.

Question 37

Bioavailability of orally administered drugs is initially associated with which physiologic phenomenon?

Answer 37

First-pass metabolism

Question 38

A patient taking clozapine (Clozaril) says, “I get plenty of vitamin C by drinking 8 ounces of grapefruit juice each morning.” Select the nurse’s best response.

Answer 38

“Try apple juice instead. Grapefruit juice can cause a bad reaction while taking clozapine.”

Question 39

Complete this sentence. Culture is a group’s shared:

Answer 39

values, beliefs, and norms.

Question 40

A patient of Cuban descent is hospitalized with depression. Which factor is most applicable to care planning?

Answer 40

With the patient’s permission, the nurse should consult with family and religious advisors to plan care.

Question 41

A nurse cares for a Chinese-American patient with major depression. After the nurse reviews the therapeutic regimen with the patient, which action should occur next?

Answer 41

Provide the information in written form to the patient.

Question 42

Which statement by a nurse speaking to a mentally ill patient best exemplifies sick religiosity?

Answer 42

“Questioning God is a common reaction to illness.”

Question 43

An individual says, “I try to live my life according to the Bible. I see myself as part of a larger plan established by God. I feel inner peace when I help others and live by the Golden Rule.” Which assessment applies? This individual is:

Answer 43

spiritually mature.

Question 44

Which account of history and symptoms is most consistent with dysthymia?

Answer 44

Depressed for 3 years; poor concentration; anhedonia; low-self esteem; indecision.

Question 45

A 74-year-old patient is admitted with anhedonia, weight loss of 20 pounds in 6 weeks, and pervasive guilt over issues that occurred in early adulthood. The patient is diagnosed with melancholic depression. Which intervention has the highest priority for inclusion in the care plan?

Answer 45

Monitor and document sleep patterns.

Question 46

Which adolescent would the nurse consider to have the highest priority for health promotion interventions aimed at reducing risk for depression? An adolescent whose history shows:

Answer 46

parents were killed in an auto accident.

Question 47

When communicating with a depressed patient with psychomotor retardation, the nurse should:

Answer 47

be prepared to wait for the patient to respond.

Question 48

After breakfast, a depressed patient pleads with the nurse, “Please let me go to my room to lie down for a while.” The nurse should:

Answer 48

explain that the patient must attend scheduled activities.

Question 49

The nurse sees a depressed patient who has psychomotor retardation leaving the dining room. The patient’s shirt is soiled from spilled food. The nurse should:

Answer 49

assist the patient to change into a clean shirt.

Question 50

A patient who started a selective serotonin reuptake inhibitor (SSRI) 3 days ago says, “This medicine isn’t working.” The nurse’s best intervention would be to:

Answer 50

explain the time lag before antidepressants relieve symptoms.

Question 51

The plan for a depressed patient includes use of cognitive therapy. The nurse supports this therapy by:

Answer 51

challenging pessimistic beliefs and recognizing the patient’s accomplishments.

Question 52

In planning care for a newly admitted patient with depression, what is the nurse’s highest priority?

Answer 52

Providing a safe environment

Question 53

This nursing diagnosis is documented for a depressed patient: situational low self-esteem, related to recent divorce, as evidenced by self-deprecatory statements and blaming self for marriage failure. Identify the best short-term outcome. Within 4 days, the patient will:

Answer 53

state that both partners had faults for the failed marriage.

Question 54

Which entry in the medical record best indicates that the treatment plan for a depressed patient was successful?

Answer 54

Gained 2 pounds; sleeping 8 hours nightly; states, “I’m feeling better about my life situation.”

Question 55

A patient says, “The doctor said I have dysthymic disorder.” What priority assessment data should the nurse obtain to confirm the diagnosis?

Answer 55

How long symptoms have persisted

Question 56

A college student who attempted suicide by overdose was treated in the emergency department and then hospitalized. Select the best initial outcome. The patient will

Answer 56

exercise self-restraint by refraining from gestures or attempts to kill self for 24 hours.

Question 57

A student tells the school nurse, “My friend threatened to take an overdose of pills.” The nurse talks to the friend who verbalized the suicidal threat. Select the most critical question for the nurse to ask.

Answer 57

“Have you been taking drugs and alcohol?”

Question 58

A nurse assesses a patient who reports feeling depressed for 2 months. The patient states, “My home was foreclosed and then my car was repossessed.” Which subsequent statement by the patient most clearly alerts the nurse to a veiled, covert suicidal plan?

Answer 58

“I have an idea that will fix everything.”

Question 59

Select the most appropriate comment by the nurse when a depressed patient says, “What’s the use in going on?”

Answer 59

“I am not sure I understand what you are saying.”

Question 60

When assessing a patient’s plan for suicide, what aspect has priority?

Answer 60

Availability of means and lethality of method.

Question 61

Four individuals have suicide plans. Which plan evidences the highest risk for completed suicide?

Answer 61

Jumping from a suspension bridge in a rural location late at night.

Question 62

A new nurse on an inpatient psychiatric unit says to a colleague, “My newest patient has schizophrenia. At least I won’t have to monitor for a suicide risk.” Select the colleague’s most accurate response.

Answer 62

“Any mental illness substantially increases the risk of suicide.”

Question 63

A depressed patient was admitted following a suicide attempt by overdose of sedatives. The patient was found by the spouse. Now the patient says, “I don’t feel like signing your papers. My partner should have let me die.” What level of suicide precautions should the nurse apply?

Answer 63

One-to-one continuous supervision by staff.

Question 64

A patient at the clinic describes periods of sadness and depression as well as episodes of elation over the past 3 years. The patient adds, “Fortunately, I have been able to keep my job despite these mood changes.” These findings are most consistent with which disorder?

Answer 64

Cyclothymic

Question 65

Which principle is most useful and effective when interacting with a patient experiencing a manic episode?

Answer 65

Use a calm, matter-of-fact approach.

Question 66

A patient with bipolar I disorder says, “I will lead the next group about medications. I have studied all the effects and problems with drugs on the Internet, so I can answer patients’ questions.” How should the nurse document this finding?

Answer 66

Limit testing

Question 67

Which nursing diagnosis has the highest priority for an extremely hyperactive manic patient who paces rapidly, exercises wildly, and is argumentative with other patients?

Answer 67

Risk for injury

Question 68

Within a 15-minute period, a patient having a manic episode voices these complaints. “Dinner was cold. The bath towels are rough. The solarium is too hot. I have a sore throat. Another patient needs a shower. The medication nurse is too slow.” The nurse should:

Answer 68

tell the patient to use the suggestion box.

Question 69

A patient with bipolar disorder is laughing and giddy one minute and seconds later is angry and sarcastic. How should the nurse document the patient’s mood?

Answer 69

Labile

Question 70

A patient’s serum lithium level is 2 mEq/L. What is the nurse’s best action?

Answer 70

Withhold the lithium, and notify the health care provider.

Question 71

A medication teaching plan for a patient receiving lithium should include:

Answer 71

dietary teaching to limit daily sodium intake.

Question 72

A patient has pain disorder. Select the best outcome criterion for the nursing diagnosis, ineffective coping, related to dependence on pain relievers. The patient will:

Answer 72

state relaxation techniques that provide pain relief.

Question 73

An adult is diagnosed with somatization disorder. The adult says, “Our family has gotten along over the years by working together. My partner cooks and the children clean house.” Nursing interventions should recognize that the patient likely:

Answer 73

will be resistant to developing a trusting relationship.

Question 74

A driver was trapped in a car for several hours after an earthquake caused a bridge to collapse. A year later, this person still has nightmares and re-experiences feelings of fear associated with being trapped in the car. The assessment findings are consistent with symptoms of:

Answer 74

posttraumatic stress disorder (PTSD).

Question 75

A patient with panic attacks awakens from sleep complaining of chest pain. The patient is diaphoretic and breathlessly says, “I feel like I’m going to die.” Select the nurse’s priority action.

Answer 75

Bring the crash cart to the patient’s room.

Question 76

The spouse of a patient with hypochondriasis says, “I’m exhausted. As soon as our bills get caught up, something else happens. I work a full time and a part-time job, do all the work at home, and take care of my partner.” Which nursing diagnosis is most applicable?

Answer 76

Caregiver role strain

Question 77

Which assessment findings validate that a patient with bipolar disorder is experiencing mania? Select all that apply.

Answer 77

Euphoria

Pacing

Question 78

What information should the nurse include in patient teaching about psychotropic medication? Select all that apply.

Answer 78

Common drug interactions
Management of common side effects
Descriptive list of all possible adverse effects
Written copies of information about the drug and its effects

Question 79

An individual has been experiencing moderate to severe anxiety. Which behaviors indicate the person is tolerating the anxiety but not managing its cause? Select all that apply.

Answer 79

Yoga
Having a massage
Listening to music