Exam 3

Question 1

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?
a. Increased muscle tension and anxiety
b. Vegetative signs and poor grooming
c. Poor judgment and hyperactivity
d. Cognitive deficits and paranoia

Answer 1

ANS: C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

Question 2

A client diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The client twirls and shadow boxes. The client says gaily, “Do you like my scarves? Here they are my gift to you.” How should the nurse document the client’s mood?
a. Euphoric
b. Irritable
c. Suspicious d. Confident

Answer 2

ANS: A
The client has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the client’s mood. Suspiciousness is not eviden

Question 3

person was directing traffic on a busy street, rapidly shouting, “To work, you jerk, for perks” and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this client’s plan of care?
a. Insulting, aggressive behavior
b. Pressured speech and grandiosity
c. Hyperactivity; not eating and sleeping
d. Poor concentration and decision making

Answer 3

ANS: C
Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the client. The other behaviors are less threatening to the client’s life.

Question 4

A client diagnosed with acute mania has distributed pamphlets about a new business venture on street corner for 2 days. Which nursing diagnosis has priority?
a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Ineffective therapeutic regimen management

Answer 4

ANS: A
Although each of the nursing diagnoses listed is appropriate for a client having a manic episode, the priority lies with the client’s physiological safety. Hyperactivity and poor judgment put the client at risk for injury

Question 5

A client diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The client threatens to hit another client. Which comment by the nurse is appropriate?
a. “Stop that! No one did anything to provoke an attack by you.”
b. “If you do that one more time, you will be secluded immediately.”
c. “Do not hit anyone. If you are unable to control yourself, we will help you.”
d. “You know we will not let you hit anyone. Why do you continue this behavior?”

Answer 5

ANS: C
When the client is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the client, threaten the client with seclusion as punishment, and ask a rhetorical question.

Question 6

This nursing diagnosis applies to a client experiencing acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5- pound weight loss in 4 days. What is an appropriate outcome for this client?
a. ask staff for assistance with feeding within 4 days.
b. drink six servings of a high-calorie, high-protein drink each day.
c. consistently sit with others for at least 30 minutes at mealtime within 1 week.
d. consistently wear appropriate attire for age and sex within 1 week while on the
psychiatric unit.

Answer 6

ANS: B
High-calorie, high-protein food supplements will provide the additional calories needed to offset the client’s extreme hyperactivity. Sitting with others or asking for assistance does not mean the client ate or drank. The other indicator is unrelated to the nursing diagnosis.

Question 7

A client demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen?
a. To minimize the side effects of lithium.
b. To bring hyperactivity under rapid control.
c. To enhance the antimanic actions of lithium.
d. To be used for long-term control of hyperactivity.

Answer 7

ANS: B
Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium’s antimanic activity nor minimize the side effects. Lithium will be used for long-term control

Question 8

. A client diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?
a. phenytoin
b. clonidine
c. risperidone
d. carbamazepine

Answer 8

ANS: D
Some clients diagnosed with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in clients with rapid cycling and in severely paranoid, angry manic clients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant.

Question 9

While the exact cause of bipolar disorder has not been determined; however, what is consistent for most clients?
a. several factors, including genetics, are implicated.
b. brain structures were altered by stress early in life.
c. excess sensitivity in dopamine receptors may trigger episodes.
d. inadequate norepinephrine reuptake disturbs circadian rhythms.

Answer 9

ANS: A
The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Question 10

The spouse of a client diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide?
a. “A high proportion of clients with bipolar disorders are found among creative writers.”
b. “A higher rate of relatives with bipolar disorder is found among clients with
bipolar disorder.”
c. “Clients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress.”
d. “More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.”

Answer 10

ANS: B
Evidence of genetic transmission is supported by lifetime prevalence statistics. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

Question 11

A client diagnosed with bipolar disorder commands other clients, “Get me a book. Take this stuff out of here,” and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select?
a. Distraction: “Let’s go to the dining room for a snack.”
b. Humor: “How much are you paying servants these days?”
c. Limit setting: “You must stop ordering other clients around.”
d. Honest feedback: “Your controlling behavior is annoying others.”

Answer 11

ANS: A
The distractibility characteristic of manic episodes can assist the nurse to direct the client toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the client or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger

Question 12

The nurse receives a laboratory report indicating a client’s serum level is 1 mEq/L. The client’s last dose of lithium was 8 hours ago. What does this result indicate?
a. within therapeutic limits.
b. below therapeutic limits.
c. above therapeutic limits.
d. invalid because of the time lapse since the last dose.

Answer 12

ANS: A
Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.6 to 1.2 mEq/L.

Question 13

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification?
a. clonazepam
b. risperidone
c. lamotrigine
d. aripiprazole

Answer 13

ANS: C
The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs

Question 14

When a hyperactive client diagnosed with acute mania is hospitalized, what is the initial nursing intervention?
a. Allow the client to act out feelings.
b. Set limits on client behavior as necessary.
c. Provide verbal instructions to the client to remain calm.
d. Restrain the client to reduce hyperactivity and aggression.

Answer 14

ANS: B
This intervention provides support through the nurse’s presence and provides structure as necessary while the client’s control is tenuous. Acting out may lead to loss of behavioral control. The client will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

Question 15

At a unit meeting, the staff discusses decor for a special room for clients with acute mania. Which suggestion is appropriate?
a. An extra-large window with a view of the street
b. Neutral walls with pale, simple accessories
c. Brightly colored walls and print drapes
d. Deep colors for walls and upholstery

Answer 15

ANS: B
The environment for a manic client should be as simple and non-stimulating as possible. Manic clients are highly sensitive to environmental distractions and stimulation.

Question 16

A client demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially?
a. Confer with the health care provider to consider use of seclusion for this client.
b. Hold a staff meeting to discuss consistency and limit-setting approaches.
c. Conduct a meeting with all staff and clients to discuss the behavior.
d. Explain to the client that the behavior is unacceptable.

Answer 16

ANS: B
When staff members are exhausted, the client has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

Question 17

A client experiencing acute mania undresses in the group room and dances. How should the nurse intervene initially?
a. quietly asking the client, “Why don’t you put your clothes on?”
b. firmly telling the client, “Stop dancing and put on your clothing.”
c. putting a blanket around the client and walking with the client to a quiet room.
d. letting the client stay in the group room and moving the other clients to a different
area.

Answer 17

ANS: C
Clients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the client from public exposure by matter-of-factly covering the client and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

Question 18

A client waves a newspaper and says, “I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes.” What is the nurse’s appropriate intervention?
a. suggesting the client have a friend do the shopping and bring purchases to the unit.
b. inviting the client to sit together and look at new fashion magazines.
c. telling the client computer use is not allowed until self-control improves.
d. asking whether the client has enough money to pay for the purchases.
.

Answer 18

ANS: B
Situations such as this offer an opportunity to use the client’s distractibility to staff’s advantage. Clients become frustrated when staff deny requests that the client sees as entirely reasonable. Distracting the client can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the client’s need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the client has enough money would likely precipitate an angry response.

Question 19

A client diagnosed with bipolar disorder who takes lithium carbonate 300 mg three times daily reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with what?
a. food.
b. an antacid.
c. an antiemetic.
d. a large glass of juice.

Answer 19

ANS: A
Some clients find that taking lithium with food diminishes nausea. The incorrect options are less helpful.

Question 20

A health teaching plan for a client taking lithium should include which instructions?
a. maintain normal salt and fluids in the diet.
b. drink twice the usual daily amount of fluid.
c. double the lithium dose if diarrhea or vomiting occurs.
d. avoid eating aged cheese, processed meats, and red wine.

Answer 20

ANS: A
Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

Question 21

Which nursing diagnosis would most likely apply to a client diagnosed with major depressive disorder as well as one experiencing acute mania?
a. Deficient diversional activity
b. Disturbed sleep pattern
c. Fluid volume excess
d. Defensive coping

Answer 21

ANS: B
Clients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for clients with depression. Defensive coping is more relevant for clients with mania. Fluid volume excess is less relevant for clients with mood disorders than is deficient fluid volume.

Question 22

Which dinner menu is best suited for a client with acute mania?
a. Spaghetti and meatballs, salad, and a banana
b. Beef and vegetable stew, a roll, and chocolate pudding
c. Broiled chicken breast on a roll, an ear of corn, and an apple
d. Chicken casserole, green beans, and flavored gelatin with whipped cream

Answer 22

ANS: C
These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive client could eat while in motion. The foods in the incorrect options cannot be eaten without utensils.

Question 23

Outcome identification for the treatment plan of a client experiencing grandiose thinking associated with acute mania will focus on what?
a. developing an optimistic outlook.
b. distorted thought self-control.
c. interest in the environment.
d. sleep pattern stabilization

Answer 23

ANS: B
The desired outcome is that the client will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Clients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes

Question 24

. Which documentation indicates that the treatment plan for a client diagnosed with acute mania has been effective?
a. “Converses with few interruptions; clothing matches; participates in activities.”
b. “Irritable, suggestible, distractible; napped for 10 minutes in afternoon.”
c. “Attention span short; writing copious notes; intrudes in conversations.”
d. “Heavy makeup; seductive toward staff; pressured speech.”

Answer 24

ANS: A
The descriptors given indicate the client is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

Question 25

A client experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the client with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

Answer 25

ANS: B All the options are reasonable interventions for a client with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

Question 26

A client with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the client’s behavior? a. Educate the client about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the client’s speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The client may not be swallowing medications.

Answer 26

ANS: D The client continues to exhibit manic symptoms. Nonadherence to the medication regime is a common problem for clients diagnosed with bipolar disorder. The lithium level should be approaching a therapeutic range after 7 days but may be low from “cheeking” (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the client does not address the problem.

Question 27

A client diagnosed with acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement? a. direct the client to wear clothes at all times. b. ask if the client finds clothes bothersome. c. tell the client that others feel embarrassed. d. arrange for one-on-one supervision.

Answer 27

ANS: D A client who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the client to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the client is bothered by clothing serves no purpose. Telling the client that others are embarrassed will not make a difference to the client whose grasp of social behaviors is impaired by the illness

Question 28

A client experiencing acute mania is dancing atop a pool table in the recreation room. The client waves a cue in one hand and says, “I’ll throw the pool balls if anyone comes near me.” To best assure safety, what is the nurse’s first intervention? a. tell the client, “You need to be secluded.” b. clear the room of all other clients. c. help the client down from the table. d. assemble a show of force.

Answer 28

ANS: B The client’s behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other clients are out of the room, a plan for managing this client can be implemented. Threatening the client or assembling a show of force is likely to exacerbate the tension

Question 29

A client diagnosed with bipolar disorder will be discharged tomorrow. The client is taking a mood stabilizing medication. What is the priority nursing intervention for the client as well as the client’s family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

Answer 29

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the client are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

Question 30

A nurse assesses a client who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

Answer 30

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

Question 31

A client diagnosed with bipolar disorder is in the maintenance phase of treatment. The client asks, “Do I have to keep taking this lithium even though my mood is stable now?” What is the nurse’s most appropriate response? a. “You will be able to stop the medication in about 1 month.” b. “Taking the medication every day helps reduce the risk of a relapse.” c. “Most clients take medication for approximately 6 months after discharge.” d. “It’s unusual that the health care provider hasn’t already stopped your medication.”

Answer 31

ANS: B Clients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the client understand this need will promote medication adherence

Question 32

. A client diagnosed with bipolar disorder is prescribed lithium. The client telephones the nurse to say, “I’ve had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?” What advise will they give to the client? a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the client to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

Answer 32

ANS: B The symptoms described suggest lithium toxicity. The client should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the client should not drive and should be accompanied by another person. The incorrect options will not ameliorate the client’s symptoms

Question 33

A client newly diagnosed with bipolar disorder is prescribed lithium. Which information from the client’s medical history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

Answer 33

ANS: D The client with heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. None of the other options would present such a challenge.

Question 34

Four new clients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these clients for safety. Which client diagnosis will need the most watchful supervision? a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder. d. cyclothymic disorder.

Answer 34

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A client with bipolar I disorder is more unstable than a client diagnosed with bipolar II cyclothymic disorder, or dysthymic disorder.

Question 35

Which suggestions are appropriate for the family of a client diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply.) a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Supervise medication administration. e. Monitor the client’s sleep patterns.

Answer 35

ANS: A, B, D, E A client with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure helps the client maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. The family should supervise medication administration to prevent deterioration to a full manic episode and because the client is at risk to omit medications.

Question 36

A nurse prepares the plan of care for a client experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Impaired mood regulation c. Sleep deprivation d. Chronic confusion e. Social isolation.

Answer 36

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. The mood evidences euphoria and is labile. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic

Question 37

A client tells the nurse, “I’m ashamed of being bipolar. When I’m manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I’m a burden to my family.” These statements support which nursing diagnoses? (Select all that apply.) a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

Answer 37

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the client’s statements. No data support the other diagnoses.

Question 38

The plan of care for a client in the manic state of bipolar disorder should include which interventions? (Select all that apply.) a. Touch the client to provide reassurance. b. Invite the client to lead a community meeting. c. Provide a structured environment for the client. d. Ensure that the client’s nutritional needs are met. e. Design activities that require the client’s concentration.

Answer 38

ANS: C,D People with mania are hyperactive, grandiose, and distractible. It is most important to ensure the client receives adequate nutrition. Structure will support a safe environment. Touching the client may precipitate aggressive behavior. Leading a community meeting would be appropriate when the client’s behavior is less grandiose. Activities that require concentration will produce frustration.

Question 39

A client became severely depressed when the last of the family’s six children moved out of the home 4 months ago. The client repeatedly says, “No one cares about me. I’m not worth anything.” Which response by the nurse would be the most helpful? a. “Things will look brighter soon. Everyone feels down once in a while.” b. “Our staff members care about you and want to try to help you get better.” c. “It is difficult for others to care about you when you repeatedly say the same negative things.” d. “I’d to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you.”

Answer 39

ANS: D Spending time with the client at intervals throughout the day shows acceptance by the nurse and will help the client establish a relationship with the nurse. The therapeutic technique is “offering self.” Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The client is unable to say positive things at this point.

Question 40

A client became depressed after the last of the family’s six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. a. The client will verbalize realistic positive characteristics about self by (date). b. The client will agree to take an antidepressant medication regularly by (date). c. The client will initiate social interaction with another person daily by (date). d. The client will identify two personal behaviors that alienate others by (date).

Answer 40

ANS: A Low self-esteem is reflected by making consistently negative statements about self and self- worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

Question 41

A client diagnosed with major depressive disorder says, “No one cares about me anymore. I’m not worth anything.” Today the client is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this client? a. “You look nice this morning.” b. “You’re wearing a new shirt.” c. “I like the shirt you are wearing.” d. “You must be feeling better today.”

Answer 41

ANS: B Clients with depression usually see the negative side of things. The meaning of compliments may be altered to “I didn’t look nice yesterday” or “They didn’t like my other shirt.” Neutral comments such as making an observation avoid negative interpretations. Saying, “You look nice” or “I like your shirt” gives approval (nontherapeutic techniques). Saying “You must be feeling better today” is an assumption, which is nontherapeutic.

Question 42

. An adult diagnosed with major depressive disorder was treated with medication and cognitive- behavioral therapy. The client now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy

Answer 42

ANS: A Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a client’s support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skills training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.

Question 43

What is the priority intervention for a client diagnosed with major depressive disorder and feelings of worthlessness? a. distracting the client from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the client to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

Answer 43

ANS: B Approximately two-thirds of people with depression contemplate suicide. Clients with depressive disorder who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the client diagnosed with depression may prevent a suicide attempt on the unit.

Question 44

When counseling clients diagnosed with major depressive disorder, what therapy would an advanced practice nurse address the client’s negative thought patterns? a. psychoanalytic b. desensitization c. cognitive-behavioral d. alternative and complementary

Answer 44

ANS: C Cognitive-behavioral therapy attempts to alter the client’s dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The client is also taught the connection between thoughts and resultant feelings. Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.

Question 45

A client says to the nurse, “My life doesn’t have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” The nurse documents this report using what medical term? a. dysthymia. b. anhedonia c. euphoria d. anergia.

Answer 45

ANS: B Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means “without energy.”

Question 46

A client diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the client says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse will implement which intervention? a. limit the client’s activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the client strategies to manage postural hypotension. d. update the client’s mental status examination.

Answer 46

ANS: C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the client to stay well hydrated and rise slowly. Knowing this information may convince the client to continue the medication. Activity is an important aspect of the client’s treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

Question 47

A client diagnosed with major depressive disorder is receiving imipramine 200 mg at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

Answer 47

ANS: D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

Question 48

A client diagnosed with major depressive disorder tells the nurse, “Bad things that happen are always my fault.” Which response by the nurse will best assist the client to reframe this overgeneralization? a. “I really doubt that one person can be blamed for all the bad things that happen.” b. “Let’s look at one bad thing that happened to see if another explanation exists.” c. “You are being extremely hard on yourself. Try to have a positive focus.” d. “Are you saying that you don’t have any good things happen?” .

Answer 48

ANS: B By questioning a faulty assumption, the nurse can help the client look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the client to evaluate the statement

Question 49

A nurse worked with a client diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the client did not improve. The nurse is most at risk for what feelings? a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

Answer 49

ANS: D Nurses may have expectations for self and clients that are not wholly realistic, especially regarding the client’s progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with clients with depression because of the client’s resistance. Guilt and despair might be seen when the nurse experiences the client’s feelings because of empathy. Interest is possible, but not the most likely result.

Question 50

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family? a. Need to restrict sodium intake to 1 gram daily. b. Need to minimize exposure to bright sunlight. c. Importance of reporting increased suicidal thoughts. d. Importance of maintaining a tyramine-free diet. .

Answer 50

ANS: C Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy

Question 51

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family? a. Need to restrict sodium intake to 1 gram daily. b. Need to minimize exposure to bright sunlight. c. Importance of reporting increased suicidal thoughts. d. Importance of maintaining a tyramine-free diet.

Answer 51

ANS: C Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

Question 52

A nurse taught a client about a tyramine-restricted diet. Which menu selection would the indicate the client understood the information? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

Answer 52

ANS: B The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

Question 53

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the client to identify and test negative thoughts

Answer 53

ANS: B During the immediate posttreatment period, the client is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the client in identifying and testing negative thoughts is inappropriate in the immediate posttreatment period because the client may be confused.

Question 54

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning? The client a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

Answer 54

D Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the client takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

Question 55

Major depressive disorder resulted after a client’s employment was terminated. The client now says to the nurse, “I’m not worth the time you spend with me. I am the most useless person in th world.” Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

Answer 55

ANS: C The client’s statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.

Question 56

A client diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the client. Which communication technique will be effective? a. Make observations. b. Ask the client direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the client to reduce guilt feelings.

Answer 56

ANS: A Making observations about neutral topics draws the client into the reality around him or her but places no burdensome expectations for answers on the client. Acceptance and support are shown by the nurse’s presence. Direct questions may make the client feel that the encounter is an interrogation. Open-ended questions are preferable if the client is able to participate in dialogue. Platitudes are never acceptable. They minimize client feelings and can increase feelings of worthlessness.

Question 57

A client being treated for depression has taken sertraline daily for a year. The client calls the clinic nurse and says, “I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can’t sleep.” The nurse will advise the client to: a. “Go to the nearest emergency department immediately.” b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.” c. “Take a dose of your antidepressant now and come to the clinic to see the health care provider.” d. “Resume taking your antidepressants for 2 more weeks and then discontinue them again.

Answer 57

ANS: C The client has symptoms associated with abrupt withdrawal of the antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the client to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the client is experiencing.

Question 58

Which documentation for a client diagnosed with major depressive disorder indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild b. Slept 10 hours uninterrupted. Attended craft group; stated “project was a failure, just like me.” c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, “I feel tired all the time.”

Answer 58

ANS: A Sleeping 6 hours, participating with a group, and anticipating an event are all positive findings that suggest effectiveness of the plan of care. All the other options show at least one negative finding.

Question 59

A client was diagnosed with seasonal affective disorder (SAD). During which month would this client’s symptoms be most acute? a. January b. April c. June d. September

Answer 59

ANS: A The days are short in January, so the client would have the least exposure to sunlight. SAD is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.

Question 60

A client diagnosed with major depressive disorder repeatedly tells staff, “I have cancer. It’s my punishment for being a bad person.” Diagnostic tests reveal no cancer. What is the priority nursing diagnosis? a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

Answer 60

ANS: B A client diagnosed with major depressive disorder who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

Question 61

A client diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this client? a. Tomato juice b. Orange juice c. Hot tea d. Milk

Answer 61

ANS: D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

Question 62

During a psychiatric assessment, the nurse observes a client’s facial expression is without emotion. The client says, “Life feels so hopeless to me. I’ve been feeling sad for several months.” How will the nurse document the client’s affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

Answer 62

ANS: B Mood refers to a person’s self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person’s expression, the affect is flat.

Question 63

A disheveled client in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. What action will the nurse take? a. bring up the issue at the community meeting. b. calmly tell the client, “You must bathe daily.” c. make observations about the client’s poor personal hygiene. d. firmly and neutrally assist the client with showering.

Answer 63

ANS: D When clients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. The client needs assistance, not simply making an observation. Calmly telling the client to bathe daily and bringing up the issue at a community meeting are punitive.

Question 64

. A client diagnosed with major depressive disorder began taking escitalopram 5 days ago. The client now says, “This medicine isn’t working.” What is the nurse’s best intervention? a. discuss with the health care provider the need to increase the dose. b. reassure the client that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the client for symptoms of improvement.

Answer 64

ANS: C Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with clients.

Question 65

. A client is experiencing psychomotor agitation associated with major depressive disorder. Which observation presented by the client would the nurse associate with this symptom? a. pacing aimlessly around the room. b. asking the nurse to repeat instructions. c. reporting prickly skin sensations. d. demonstrating slowed verbal responses.

Answer 65

ANS: A Psychomotor agitation may be evidenced by constant pacing and wringing of hands. Slowed movements and responses are aspects of psychomotor retardation. Complaints of the unusual skin sensations may represent a delusion or hallucination. Asking the nurse to repeat instructions indicates difficulty with concentration

Question 66

A client diagnosed with major depressive disorder received six electroconvulsive therapy (ECT) sessions and aggressive doses of antidepressant medication. The client owns a small business an was counseled not to make major decisions for a month. What is the correct rationale for this counseling? a. Antidepressant medications alter catecholamine levels, which impairs decision- making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with ECT. d. The client needs time to readjust to a pressured work schedule.

Answer 66

ANS: C Recent memory impairment and/or confusion may be present during and for a short time after ECT. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The client needing time to reorient to a pressured work schedule is less relevant than the correct rationale.

Question 67

A nurse instructs a client taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of what? a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

Answer 67

ANS: B Clients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

Question 68

Transcranial Magnetic Stimulation (TCM) is scheduled for a client diagnosed with major depressive disorder. Which comment by the client indicates teaching about the procedure was effective? a. “They will put me to sleep during the procedure, so I won’t know what is happening.” b. “I might be a little dizzy or have a mild headache after each procedure.” c. “I will be unable to care for my children for about 2 months.” d. “I will avoid eating foods that contain tyramine.”

Answer 68

ANS: B TCM treatments take about 30 minutes. Treatments are usually 5 days a week. Clients are awake and alert during the procedure. After the procedure, clients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The client will be able to care for children.

Question 69

The admission note indicates a client diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.) a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

Answer 69

ANS: C, D, E Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

Question 70

A nurse caring for a client diagnosed with major depressive disorder reads in the client’s medical record, “This client shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.) a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

Answer 70

ANS: A, C, D, F Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self.

Question 71

A client diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.) a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

Answer 71

ANS: A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the client feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.

Question 72

A client being treated with paroxetine 50 mg po daily reports to the clinic nurse, “I took a few extra tablets earlier today and now I feel bad.” Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

Answer 72

ANS: A, D, E The client is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Serotonin syndrome must be considered. Symptoms include abdominal pain diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Serotonin syndrome may progress to a full medical emergency if not treated early. The client may have urinary retention, but frequency would not be expected.

Question 73

. A nurse wants to teach alternative coping strategies to a client experiencing severe anxiety. Which action should the nurse perform first? a. Verify the client’s learning style. b. Lower the client’s current anxiety. c. Create outcomes and a teaching plan. d. Assess how the client uses defense mechanisms.

Answer 73

ANS: B A client experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A client experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the client’s anxiety level. Use of defense mechanisms does not apply.

Question 74

A nurse’s neighbor says, “I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?” The nurse should respond by noting that what serious medical conditions may be complicated by emotional stress? (Select all that apply.) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.

Answer 74

ANS: A, C, D, E A number of diseases can be worsened or brought to awareness by intense emotional stress. Immune disorders can be complicated associated with detrimental effects of stress on the immune system. Others can be brought about indirectly, such as cardiovascular disease due to acute or chronic hypertension. Hip fractures are not in this group.

Question 75

Over the past year, a client has cooked gourmet meals for the family but eats only tiny servings. This person wears layered loose clothing and currently weighs 95 pounds, after a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

Answer 75

ANS: C Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The client with eating disorder not otherwise specified may be obese.

Question 76

Disturbed body image is a nursing diagnosis established for a client diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the client d. Client expresses satisfaction with body appearance

Answer 76

ANS: D Body image disturbances are considered improved or resolved when the client is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

Question 77

A client referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the client which question? a. “Do you often feel fat?” b. “Who plans the family meals?” c. “What do you eat in a typical day?” d. “What do you think about your present weight?”

Answer 77

ANS: C Although all the questions might be appropriate to ask, only “What do you eat in a typical day?” focuses on the eating patterns. Asking if the client often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the client’s thoughts on present weight explores the client’s feelings about weight.

Question 78

A client diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, “Describe what you think about your present weight and how you look.” Which response by the client is most consistent with the diagnosis? a. “I am fat and ugly.” b. “What I think about myself is my business.” c. “I’m grossly underweight, but that’s what I want.” d. “I’m a few pounds’ overweight, but I can live with it.”

Answer 78

ANS: A Untreated clients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The client with anorexia will usually tell people perceptions of self. The client with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

Question 79

A client was diagnosed with anorexia nervosa. The history shows the client virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

Answer 79

ANS: D The client’s history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the client uses laxatives, induces vomiting, or exercises excessively. The client has hypokalemia rather than hyperkalemia.

Question 80

Outpatient treatment is planned for a client diagnosed with anorexia nervosa. What is the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements that should be achieved within 1 week? a. weighs self accurately using balanced scales. b. limits exercise to less than 2 hours daily. c. selects clothing that fits properly. d. gains 1 to 2 pounds.

Answer 80

ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the client is an outpatient. The focus of an outcome would not be on the client weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

Question 81

Which nursing intervention has the highest priority as a client diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the client’s feelings. d. Help the client balance energy expenditures with caloric intake.

Answer 81

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relates to coping. Helping the client achieve balance between energy expenditure and caloric intake is an inappropriate intervention. PTS: 1 DIF: Cognitive Level: Appl

Question 82

A client diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the client to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Client involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the client’s permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

Answer 82

ANS: B A sense of control for the client is vital to the success of therapy. A diet that controls weight gai can allay client fears of too-rapid weight gain. Data collection is not the reason for contracting. team approach is wise but is not a guarantee that needs will be met. Permission for treatment is separate issue. The contract for weight gain is an additional aspect of treatment.

Question 83

The nursing care plan for a client diagnosed with anorexia nervosa includes the intervention “monitor for complications of refeeding.” Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Integumentary d. Cardiovascular

Answer 83

ANS: D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascula collapse. Focused assessment is a necessity to ensure the client’s physiological integrity. The other body systems are not initially involved in the refeeding syndrome.

Question 84

A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a client diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. “What are your feelings about not eating foods that you prepare?” b. “You seem to feel much better about yourself when you eat something.” c. “It must be difficult to talk about private matters to someone you just met.” d. “Being thin doesn’t seem to solve your problems. You are thin now but still unhappy.”

Answer 84

ANS: D The correct response is the only strategy that questions the client’s distorted thinking.

Question 85

What is an appropriate intervention for a client diagnosed with bulimia nervosa who binges, and purges is to teach the client? a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.

Answer 85

ANS: B One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the client to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the client to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.

Question 86

A nurse provides care for an adolescent client diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the client in a protective fashion. b. The nurse’s comments to the client are compassionate and nonjudgmental. c. The nurse teaches the client to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the client to a self-help group for individuals with eating disorders.

Answer 86

ANS: A In the effort to motivate the client and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent’s role. The helpful nurse uses a problem-solving approach and focuses on the client’s feelings of shame and low self-esteem. Referring a client to a self-help group is an appropriate intervention.

Question 87

A nursing diagnosis for a client diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. What is the best outcome related to this diagnosis that should be achieved within 2 weeks? a. appropriately expressing angry feelings. b. verbalizing two positive things about self. c. verbalizing the importance of eating a balanced diet. d. identifying two alternative methods of coping with loneliness.

Answer 87

D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

Question 88

Which nursing intervention has the highest priority for a client diagnosed with bulimia nervosa? a. Assist the client to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

Answer 88

ANS: A For most clients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge–purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

Question 89

One bed is available on the inpatient eating-disorder unit. A client with which assessment data should be admitted to this bed? a. Going from 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. Going from120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. Going from110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. Going 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

Answer 89

ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, weighs below 75% of ideal body weight, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

Question 90

A nurse provides health teaching for a client diagnosed with bulimia nervosa. What is the priority information the nurse should provide? a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

Answer 90

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the client can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the client purges. Daily weight gain may not be desirable for a client with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

Question 91

As a client admitted to the eating-disorder unit undresses, a nurse observes that the client’s body is covered by fine, downy hair. The client weighs 70 pounds and is 5'4" tall. Which term should be used in the documentation of this assessment finding? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

Answer 91

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in clients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

Question 92

A client being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The client weighs 70 pounds; height is 5'4". The client says, “I won’t eat until I look thin.” What is the priority initial nursing diagnosis? a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation

Answer 92

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the client’s self-starvation is the priority.

Question 93

Why does the nurse conducting group therapy on the eating-disorder unit schedule the sessions immediately after meals? a. maintains clients’ concentration and attention. b. shifts the clients’ focus from food to psychotherapy. c. promotes processing of anxiety associated with eating. d. focuses on weight control mechanisms and food preparation.

Answer 93

ANS: C Eating produces high anxiety for clients with eating disorders. Anxiety levels must be lowered if the client is to be successful in attaining therapeutic goals. Shifting the clients’ focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining clients’ concentration and attention is important, but not the primary purpose of the schedule.

Question 94

What does the physical assessment of a client diagnosed with bulimia often reveal? a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.

Answer 94

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

Question 95

Which personality characteristic is a nurse most likely to assess in a client diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

Answer 95

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of clients with eating disorders. The incorrect options are rare in a client with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

Question 96

Which assessment finding for a client diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hour b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg

Answer 96

ANS: D Systolic blood pressure less than 90 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hour. A potassium level of 3.4 mEq/L is within the normal range.

Question 97

A nurse finds a client diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. “You and I will have to sit down and discuss this problem.” b. “It bothers me to see you exercising. I am afraid you will lose more weight.” c. “Let’s discuss the relationship between exercise, weight loss, and the effects on your body.” d. “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.”

Answer 97

ANS: D A matter-of-fact statement that the nurse’s perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Clients must be held accountable for required behaviors.

Question 98

Which nursing diagnosis is more appropriate for a client diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound client diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

Answer 98

ANS: D The client with bulimia nervosa usually maintains a close to normal weight, whereas the client with anorexia nervosa may approach starvation. The incorrect options may be appropriate for clients with either anorexia nervosa or bulimia nervosa.

Question 99

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the client gained 8 pounds. What intervention should the nurse implement initially? a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the client for the weight gain. d. establish a higher goal for weight gain the next week.

Answer 99

A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart’s capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

Question 100

The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a client diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? a. The client’s history of poly-substance abuse b. The client’s preference for homeopathic remedies c. The client’s family history of autoimmune disorders d. The client’s comorbid diagnosis of a learning disability

Answer 100

ANS: A Lisdexamfetamine dimesylate is designed to suppress the appetite and presents a risk for abuse. The client with a history of substance abuse is at risk to abuse this medication as well. The client’s preference for homeopathic remedies is a consideration, but the history of substance abuse has a higher priority. Lisdexamfetamine dimesylate is commonly used to treat attention deficit hyperactivity disorder rather than learning disabilities. A history of autoimmune disorders in the family is irrelevant.

Question 101

A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? a. The child frequently eats newspapers and magazines. b. The child refuses to eat peanut butter and jelly sandwiches. c. The child often rechews and re-swallows foods at mealtimes. d. The parents feed the child clay because of concerns about anemia.

Answer 101

ANS: A Pica refers to eating nonfood items after maturing past toddlerhood. Some cultures practice eating nonfood items; however, this factor is a cultural preference rather than a disorder. Refusing to eat peanut butter and jelly sandwiches is an example of a simple food preference in child. Rumination refers to regurgitation with rechewing, re-swallowing, or spitting.

Question 102

A client referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physica manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

Answer 102

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

Question 103

A client diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.) a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

Answer 103

ANS: C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the client’s eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe clients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

Question 104

A nurse would determine that which client has the highest risk for problems with sleep physiology? a. Retiree who volunteers twice a week at Habitat for Humanity b. Corporate accountant who travels frequently c. Parent with three teenagers d. Lawn care w

Answer 104

B

Question 105

What are the primary distinguishing factors between the behavior of persons diagnosed with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? The person diagnosed with (Select all that apply.) a. The person diagnosed with ODD relives traumatic events by acting them out. b. The person diagnosed with ODD tests limits and disobeys authority figures. c. The person diagnosed with ODD has difficulty separating from loved ones. d. The person diagnosed with CD uses stereotypical or repetitive language. e. The person diagnosed with CD often violates the rights of others.

Answer 105

ANS: B, E Persons diagnosed with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas persons with CD frequently behav in ways that do violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with PTSD. Stereotypical language behaviors are seen in persons with autism spectrum disorders.

Question 106

A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Why is establishing rapport with this adolescent is a priority? (Select all that apply.) a. it is a vital component of implementing a behavior modification program. b. a therapeutic alliance is the first step in a nurse’s therapeutic use of self. c. the adolescent has demonstrated resistance to other authority figures. d. acceptance and trust convey feelings of security for the adolescent. e. adolescents usually relate better to authority figures than peers.

Answer 106

ANS: B, D Trust is frequently an issue because the adolescent may never have had a trusting relationship with an adult. Trust promotes feelings of security and is the basis of the nurse’s therapeutic use of self. Adolescents value peer relationships over those related to authority. Rewards for appropriate behavior are the main component of behavior modification programs.

Question 107

A Client diagnosed with alcohol use disorder asks, “How will Alcoholics Anonymous (AA) help me?” What is the nurse’s best response? a. “The goal of AA is for members to learn controlled drinking with the support of a higher power.” b. “An individual is supported by peers while striving for abstinence one day at a time.” c. “You must make a commitment to permanently abstain from alcohol and other drugs.” d. “You will be assigned a sponsor who will plan your treatment program.”

Answer 107

ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

Question 108

A nurse reviews vital signs for a client admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/minute 0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse’s priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the Client in a vest-type restraint.

Answer 108

ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for detox with medical intervention to prevent a hypertensive crisis and/or seizures. No indication is present that the Client may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

Question 109

A nurse cares for a client experiencing an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurological d. Hepatic

Answer 109

ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority.

Question 110

A client admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. Th client is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 13 beats/minute. The client shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” Wha is the most accurate assessment of this situation? a. The client is attempting to obtain attention by manipulating staff. b. The client may have sustained a head injury before admission. c. The client has symptoms of alcohol withdrawal delirium. d. The client is having an acute psychosis.

Answer 110

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

Question 111

A client admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The client is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

Answer 111

ANS: D The client’s clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care since none are related to the client’s physical needs.

Question 112

A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe what medication intervention? a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.

Answer 112

ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. The client’s highest needs related to a need for calming.

Question 113

A hospitalized Client diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The client is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the client every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

Answer 113

ANS: B One-on-one supervision is necessary to promote physical safety until sedation reduces the Client’s feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

Question 114

A client diagnosed with alcohol use disorder says, “Drinking helps me cope with being a single parent.” Which therapeutic response by the nurse would help the client conceptualize the drinking objectively? a. “Sooner or later, alcohol will kill you. Then what will happen to your children?” b. “I hear a lot of defensiveness in your voice. Do you really believe this?” c. “If you were coping so well, why were you hospitalized again?” d. “Tell me what happened the last time you drank.”

Answer 114

ANS: D The correct response will help the client see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the client become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the client still needs. They reflect the nurse’s frustration with the client.

Question 115

A Client asks for information about alcoholics anonymous (AA). What is the nurse’s best response? “ a. AA is a form of group therapy led by a psychiatrist.” b. AA is a self-help group for which the goal is sobriety.” c. AA is a group that learns about drinking from a group leader.” d. AA is a network that advocates strong punishment for drunk drivers.”

Answer 115

ANS: B AA is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed. AA does not advocate punishment but supports accountability for one’s actions.

Question 116

Police bring a client to the emergency department after an automobile accident. The client demonstrates poor coordination and slurred speech, but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? a. The client rarely drinks alcohol. b. The client has a high tolerance to alcohol. c. The client has been treated with disulfiram. d. The client has ingested both alcohol and sedative drugs recently.

Answer 116

ANS: B A nontolerant drinker would have sleepiness and significant changes in vital signs with a blood alcohol level of 300 mg/dL (0.30 g/dL). The fact that the client is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the client’s body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

Question 117

A client admitted to an alcohol rehabilitation program tells the nurse, “I’m actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening.” The client is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

Answer 117

ANS: A Minimizing one’s drinking is a form of denial of alcoholism. The Client is more than a social drinker. Projection involves blaming another for one’s faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into one’s own personality.

Question 118

Which medication to maintain abstinence would most likely be prescribed for clients diagnosed with an addiction to either alcohol or opioids? a. Bromocriptine b. Methadone c. Disulfiram d. Naltrexone

Answer 118

ANS: D Naltrexone is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving. None of the other options are associated with such a response.

Question 119

During the third week of treatment, the spouse of a client in a rehabilitation program for substance abuse says, “After this treatment program, I think everything will be all right.” Which remark by the nurse will be most helpful to the spouse? a. “While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol.” b. “It will be important for you to structure life to avoid as much stress as you can and provide social protection.” c. “Addiction is a lifelong disease of self-destruction. You will need to observe your spouse’s behavior carefully.” d. “It is good that you are supportive of your spouse’s sobriety and want to help maintain it.”

Answer 119

ANS: A During recovery, clients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

Question 120

The treatment team discusses the plan of care for a client diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should consider what intervention? a. provide long-term care for the client in a residential facility. b. withdraw the client from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

Answer 120

ANS: C Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.

Question 121

What is the most therapeutic characteristics for a nurse working with a client beginning treatment for alcohol addiction to present? a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

Answer 121

A Support and empathy assist the client to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase client anxiety and cause the client to cling to defenses.

Question 122

Which features should be present in a therapeutic milieu for a client experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

Answer 122

ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a “bad trip.”

Question 123

When a client first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

Answer 123

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change

Question 124

At a meeting for family members of alcoholics, a spouse says, “I did everything I could to help. even requested sick leave when my partner was too drunk to go to work.” The nurse assesses these comments as what? a. codependence. b. assertiveness. c. role reversal. d. homeostasis.

Answer 124

A Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario.

Question 125

In the emergency department, a client’s vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. What is the priority outcome? a. The client will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. c. The client will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the client’s breath sounds will be clear bilaterally and throughout lung fields.

Answer 125

ANS: B The correct short-term outcome is the only one that relates to the client’s physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The client’s respirations are slow and shallow, but there is no evidence of congestion.

Question 126

Family members of an individual undergoing a residential alcohol rehabilitation program ask, “How can we help?” What is the nurse’s best response? a. “Alcoholism is a lifelong disease. Relapses are expected.” b. “Use search and destroy tactics to keep the home alcohol free.” c. “It’s important that you visit your family member on a regular basis.” d. “Make your loved one responsible for the consequences of behavior.”

Answer 126

ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

Question 127

Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability.

Answer 127

ANS: D The individual must have completed withdrawal and achieved physiological stability before he or she is able to address any of the other treatment goals.

Question 128

A client diagnosed with an antisocial personality disorder was treated several times for substanc abuse, but each time the client relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

Answer 128

ANS: D Residential programs and therapeutic communities help clients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, become self-reliant, and practic honesty. Residential programs are more effective for clients with antisocial tendencies than outpatient programs.

Question 129

What is the priority nursing intervention when caring for a client after an overdose of amphetamines? a. Monitor vital signs. b. Observe for depression. c. Awaken the client every 15 minutes. d. Use warmers to maintain body temperature.

Answer 129

ANS: A An overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This client will be hypervigilant it is not necessary to awaken the client.

Question 130

Which symptoms of withdrawal from opioids should the nurse assess for? a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache

Answer 130

B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.

Question 131

A client has smoked two packs of cigarettes daily for many years. When the client tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario should be described using which term? a. cross-tolerance. b. substance abuse. c. substance addiction. d. substance intoxication.

Answer 131

ANS: C Nicotine meets the criteria for a “substance,” the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.

Question 132

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

Answer 132

ANS: D Heroin, an opiate, is a central nervous system (CNS) depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

Question 133

An adult in the emergency department states, “Everything I see appears to be waving. I am outside my body looking at myself. I think I’m losing my mind.” When vital signs are slightly elevated what should the nurse suspect? a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

Answer 133

ANS: B The client who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going “crazy.” Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements

Question 134

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine (IOM)–National Research Council c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

Answer 134

ANS: A The SAMHSA is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

Question 135

A client is thin, tense, jittery, and has dilated pupils. The client says, “My heart is pounding in my chest. I need help.” The client allows vital signs to be taken but then becomes suspicious and says, “You could be trying to kill me.” The client refuses further examination. Abuse of which substance is most likely? a. phencyclidine (PCP) b. Heroin c. Barbiturates d. Amphetamines

Answer 135

ANS: D The physical symptoms are consistent with central nervous system (CNS) stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression

Question 136

What is the priority outcome for a client completing the fourth alcohol detoxification program in the past year? a. Prior to discharge, the client will state, “I know I need long-term treatment.” b. Prior to discharge, the client will use denial and rationalization in healthy ways. c. Prior to discharge, the client will identify constructive outlets for expression of anger. d. Prior to discharge, the client will develop a trusting relationship with one staff member.

Answer 136

ANS: A The correct response recognizes the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

Question 137

A nurse prepares for an initial interaction with a client with a long history of methamphetamine abuse. Which is the nurse’s best first action? a. Perform a thorough assessment of the client. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

Answer 137

ANS: C The nurse should show compassion, care, and helpfulness for all clients, including those with addictive diseases. It is important to have a clear understanding of one’s own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

Question 138

A client undergoing alcohol rehabilitation decides to begin disulfiram therapy. Client teaching should include the need to (Select all that apply.) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

Answer 138

ANS: B, C, F The Client must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

Question 139

The nurse can assist a client to prevent substance abuse relapse by (Select all that apply.) a. rehearsing techniques to handle anticipated stressful situations. b. advising the client to accept residential treatment if relapse occurs. c. assisting the client to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the client of physical changes to expect as the body adapts to functioning without substances.

Answer 139

ANS: A, C, E Nurses can be helpful as a client assesses needed life skills and in providing appropriate referrals Anticipatory problem solving and role playing are good ways of rehearsing effective strategies for handling stressful situations and helping the client evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Clients need the support of friends and family to establish and maintain sobriety.

Question 140

After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.) a. Refer the nurse to a peer assistance program. b. Confront the nurse in the presence of a witness. c. Immediately terminate the nurse’s employment. d. Relieve the nurse of responsibilities for client care. e. Require the nurse to undergo immediate drug testing.

Answer 140

ANS: A, D Registered nurses may have personal substance use problems. The nursing supervisor should provide for safe client care by relieving the nurse of responsibility for client care. For those nurses experiencing addictions, there are nonpunitive alternatives to discipline programs in the form of peer assistance. Many state boards of nursing have developed an alternative to discipline program to help impaired nurses. Terminating the nurse’s employment and confronting the nurse in the presence of a witness are punitive actions. The peer assistance program will manage drug testing.

Question 141

A new client beginning an alcohol rehabilitation program says, “I’m just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening.” Which responses by the nurse will be most therapeutic? (Select all that apply.) a. “I see,” and use interested silence. b. “I think you are drinking more than you report.” c. “Social drinkers have one or two drinks, once or twice a week.” d. “You describe drinking steadily throughout the day and evening.” e. “Your comments show denial of the seriousness of your problem.”

Answer 141

ANS: C, D The correct answers give information, summarize, and validate what the client reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.