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Flashcards in Final - Ch 14-18 Deck (95):
1

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?

A.
Risk for injury R/T central nervous system stimulation.
B.
Disturbed thought processes R/T tactile hallucinations.
C.
Ineffective coping R/T powerlessness over alcohol use.
D.
Ineffective denial R/T continued alcohol use despite negative consequences.

A

2

A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence?

A.
Narcotic pain medication is contraindicated for all clients with active substance-abuse problems.
B.
Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
C.
There is no need to assess the client for substance dependence. There is an obvious PCA malfunction, because these clients have a higher pain tolerance.
D.
The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

B

3

On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?

A.
Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B.
Educate the client about the biopsychosocial consequences of alcohol abuse.
C.
Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
D.
Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

C

4

Which client statement indicates a knowledge deficit related to substance abuse?

A.
“Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
B.
“Tolerance to heroin develops quickly.”
C.
“Flashbacks from LSD use may reoccur spontaneously.”
D.
“Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”

D

5

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual’s situation?

A.
Psychological dependency
B.
Physical dependency
C.
Substance dependency
D.
Social dependency

A

6

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?

A.
Antagonist therapy
B.
Deterrent therapy
C.
Codependency therapy
D.
Substitution therapy

D

7

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to Alcoholics Anonymous (AA), would be most appropriate for a nurse to discuss with the client during discharge teaching?

A.
After discharge, the client will immediately attend 90 AA meetings in 90 days.
B.
After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C.
After discharge, the client will incorporate family in AA attendance.
D.
After discharge, the client will seek appropriate deterrent medications through AA.

A

8

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. When the nurse reports to the ED physician, which client symptom should be the nurse’s first priority?

A.
Tactile hallucinations
B.
Blood pressure of 180/100 mm Hg
C.
Mood rating of 2/10 on numeric scale
D.
Dehydration

B

9

Which client statement demonstrates positive progress toward recovery from substance abuse?

A.
“I have completed detox and therefore am in control of my drug use.”
B.
“I will faithfully attend Narcotic Anonymous (NA) when I can’t control my carvings.”
C.
“As a church deacon, my focus will now be on spiritual renewal.”
D.
“Taking those pills got out of control. It cost me my job, marriage, and children.”

D

10

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s rationale for this intervention?

A.
To assess for emotional strength.
B.
To assess for Wernicke-Korsakoff syndrome.
C.
To assess for tachycardia.
D.
To assess for fine tremors.

D

11

Upon admission to an inpatient treatment facility for symptoms of alcohol withdrawal, a client states, “I haven’t eaten in 3 days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?

A.
Knowledge deficit
B.
Fluid volume excess
C.
Imbalanced nutrition: less than body requirements
D.
Ineffective individual coping

C

12

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?

A.
“I’m not going to use heroin ever again. I know I’ve got the willpower to do it this time.”
B.
“I cannot control my use of heroin. It’s stronger than I am.”
C.
“I’m going to get all my children back. They need their mother.”
D.
“Once I deal with my childhood physical abuse, recovery should be easy.”

B

13

A client’s wife has been making excuses for her alcoholic husband’s work absences. In family therapy, she states, “His problems at work are my fault.” Which is the appropriate nursing response?

A.
“Why do you assume responsibility for his behaviors?”
B.
“Codependency is a typical behavior of spouses of alcoholics.”
C.
“Your husband needs to deal with the consequences of his drinking.”
D.
“Do you understand what the term enabler means?”

C

14

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?

A.
Haloperidol (Haldol) and fluoxetine (Prozac)
B.
Carbamazepine (Tegretol) and donepezil (Aricept)
C.
Disulfiram (Antabuse) and lorazepan (Ativan)
D.
Chlordiazepoxide (Librium) and phenytoin (Dilantin)

D

15

During group therapy, a client diagnosed with chronic alcohol dependence states, “I would not have boozed it up if my wife hadn’t been nagging me all the time to get a job. She never did think that I was good enough for her.” How should a nurse interpret this statement?

A.
The client is using denial by avoiding responsibility.
B.
The client is using displacement by blaming his wife.
C.
The client is using rationalization to excuse his alcohol dependence.
D.
The client is using reaction formation by appealing to the group for sympathy.

C

16

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?

A.
The client will identify one person to turn to for support.
B.
The client will give up all old drinking buddies.
C.
The client will be able to verbalize the effects of alcohol on the body.
D.
The client will correlate life problems with alcohol use.

D

17

A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?

A.
50 mg/dL
B.
100 mg/dL
C.
250 mg/dL
D.
300 mg/dL

B

18

A client has a history of drinking one pint of bourbon per day for the past 6 months. He is brought to an emergency department by family members who report that his last drink was 1 hour ago. It is now 12 a.m. When should a nurse expect this client to begin experiencing withdrawal symptoms?

A.
Between 3 a.m. and 11 a.m.
B.
Shortly after a 24-hour period.
C.
At the beginning of the third day.
D.
Withdrawal is individualized and cannot be predicted.

A

19

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?

A.
Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
B.
Sedative-hypnotics are expensive and have numerous side effects.
C.
Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
D.
Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

A

20

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?

A.
Assess for medication noncompliance.
B.
Note escalating behaviors and intervene immediately.
C.
Interpret attempts at communication.
D.
Assess triggers for bizarre, inappropriate behaviors.

B

21

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse’s teaching?

A.
The side effects of medications
B.
Deep breathing techniques to decrease stress
C.
How to make eye contact when communicating
D.
How to be a leader

C

22

A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing response?

A.
“Your child has a chemical imbalance of the brain, which leads to altered thoughts.”
B.
“Your child’s hallucinations are caused by medication interactions.”
C.
“Your child has too little serotonin in the brain, causing delusions and hallucinations.”
D.
“Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”

A

23

Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing response?

A.
“Tell him to stop discussing the voices.”
B.
“Ignore what he is saying, while attempting to discover the underlying cause.”
C.
“Focus on the feelings generated by the hallucinations and present reality.”
D.
“Present objective evidence that the voices are not real.”

C

24

A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, “Do you receive special messages from certain sources, such as the television or radio?” For which potential symptom of this disorder is the nurse assessing?

A.
Thought insertion
B.
Paranoid delusions
C.
Magical thinking
D.
Delusions of reference

D

25

A client diagnosed with schizophrenia tells a nurse, “The ‘Shopatouliens’ took my shoes out of my room last night.” Which is an appropriate charting entry to describe this client’s statement?

A.
“The client is experiencing command hallucinations.”
B.
“The client is expressing a neologism.”
C.
“The client is experiencing a paranoid delusion.”
D.
“The client is verbalizing a word salad.”

B

26

During an admission assessment, a nurse asks a client diagnosed with schizophrenia, “Have you ever felt that certain objects or persons have control over your behavior?” For which type of thought disruption is the nurse assessing?

A.
Delusion of persecution
B.
Delusions of influence
C.
Delusions of reference
D.
Delusions of grandeur

B

27

A client diagnosed with schizophrenia states, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate nursing response?

A.
“Did you take your medicine this morning?”
B.
“You are not going to hell. You are a good person.”
C.
“I’m sure the voices sound scary, but the devil is not talking to you. This is part of your illness.”
D.
“The devil only talks to people who are receptive to his influence.”

C

28

A client diagnosed with psychosis NOS tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?

A.
Disturbed sensory perception
B.
Altered thought processes
C.
Risk for violence: directed toward others
D.
Risk for injury

C

29

Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia?

A.
Provide neon lights and soft music.
B.
Maintain continual eye contact throughout the interview.
C.
Use therapeutic touch to increase trust and rapport.
D.
Provide personal space to respect the client’s boundaries.

D

30

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?

A.
Establishing personal contact with family members.
B.
Being reliable, honest, and consistent during interactions.
C.
Sharing limited personal information.
D.
Sitting close to the client to establish rapport.

B

31

A client diagnosed with paranoid schizophrenia states, “My psychiatrist is out to get me. I’m sad that the voice is telling me to stop him.” What symptom is the client exhibiting, and what is the nurse’s legal responsibility related to this symptom?

A.
Magical thinking; administer an antipsychotic medication.
B.
Persecutory delusions; orient the client to reality.
C.
Command hallucinations; warn the psychiatrist.
D.
Altered thought processes; call an emergency treatment team meeting.

C

32

Which statement should indicate to a nurse that an individual is experiencing a delusion?

A.
“There’s an alien growing in my liver.”
B.
“I see my dead husband everywhere I go.”
C.
“The IRS may audit my taxes.”
D.
“I’m not going to eat my food. It smells like brimstone.”

A

33

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom?

A.
Haloperidol (Haldol) to address the negative symptom.
B.
Clonazepam (Klonopin) to address the positive symptom.
C.
Risperidone (Risperdal) to address the positive symptom.
D.
Clozapine (Clozaril) to address the negative symptom.

C

34

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

A.
Tactile hallucinations
B.
Tardive dyskinesia
C.
Restlessness and muscle rigidity
D.
Reports of hearing disturbing voices

C

35

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client’s positive and negative symptoms of schizophrenia?

A.
Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.
B.
Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.
C.
Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
D.
Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

B

36

A 60-year-old client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

A.
Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications.
B.
Agranulocytosis treated by administration of clozapine (Clozaril).
C.
Extrapyramidal symptoms treated by administration of benztropine (Cogentin).
D.
Tardive dyskinesia treated by discontinuing antipsychotic medications.

D

37

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5?C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?

A.
Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium).
B.
Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication.
C.
Dystonia treated by administering trihexyphenidyl (Artane).
D.
Dystonia treated by administering bromocriptine (Parlodel).

A

38

A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse address first?

A.
Respirations of 22 beats/minute
B.
Weight gain of 8 pounds in 2 months
C.
Temperature of 104°F (40°C)
D.
Excessive salivation

C

39

An aging client diagnosed with chronic schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?

A.
“Make sure you concentrate on taking slow, deep, cleansing breaths.”
B.
“Watch your diet and try to engage in some regular physical activity.”
C.
“Rise slowly when you change position from lying to sitting or sitting to standing.”
D.
“Wear sunscreen and try to avoid midday sun exposure.”

C

40

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately?

A.
Sore throat, fever, and malaise
B.
Akathisia and hypersalivation
C.
Akinesia and insomnia
D.
Dry mouth and urinary retention

A

41

If clozapine (Clozaril) therapy is being considered, which laboratory test should a nurse review to establish a baseline for comparison to evaluate a potentially life-threatening side effect?

A.
While blood cell count
B.
Liver function studies
C.
Creatinine clearance
D.
Blood urea nitrogen

A

42

During an admission assessment, a nurse assesses that a client, diagnosed with schizophrenia, has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated?

A.
Haloperidol (Haldol), because it is used only in older patients.
B.
Clozapine (Clozaril), because it is incompatible with desipramine.
C.
Risperidone (Risperdal), because it exacerbates symptoms of depression.
D.
Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines.

D

43

A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?

A.
Administering lorazepam (Ativan) prn, because the client is angry at exposure of plan.
B.
Establishing room restrictions, because the client’s threat is an attempt to manipulate the staff.
C.
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.
D.
Calling an emergency treatment team meeting, because the client’s threat must be addressed.

C

44

In planning care for a suicidal client, which outcome should be a nurse’s first priority?

A.
The client will not physically harm self.
B.
The client will express hope for the future by day 3.
C.
The client will establish a trusting relationship with the nurse.
D.
The client will remain safe during hospital stay.

D

45

A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment. What is the nurse’s rationale for this procedure?

A.
To prevent increased intracranial pressure resulting from anoxia.
B.
To prevent decreased blood pressure, pulse, and respiration due to electrical stimulation.
C.
To prevent anoxia due to medication-induced paralysis of respiratory muscles.
D.
To prevent blocked airway, resulting from seizure activity.

C

46

Immediately after electroconvulsive therapy, in which position should a nurse place the client?

A.
On his or her side to prevent aspiration.
B.
In high Fowler’s position to promote consciousness.
C.
In Trendelenburg’s position to promote blood flow to vital organs.
D.
In prone position to prevent airway blockage

A

47

A client is diagnosed with dysthymic disorder. Which symptom should a nurse classify as an affective symptom of this disorder?

A.
Social isolation with a focus on self.
B.
Low energy level.
C.
Difficulty concentrating.
D.
Gloomy and pessimistic outlook on life.

D

48

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder?

A.
Altered communication R/T feelings of worthlessness AEB anhedonia.
B.
Social isolation R/T poor self-esteem AEB secluding self in room.
C.
Altered thought processes R/T hopelessness AEB persecutory delusions.
D.
Altered nutrition: less than body requirements R/T high anxiety AEB anorexia.

B

49

A client diagnosed with major depression with psychotic features hears voices commanding self-harm. A nurse is unable to elicit a contract for safety. What should be the nurse’s priority intervention at this time?

A.
Obtaining an order for locked seclusion until client is no longer suicidal.
B.
Conducting 15-minute checks to ensure safety.
C.
Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
D.
Encouraging client to express feelings related to suicide.

C

50

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis?

A.
The client is disheveled and malodorous.
B.
The client refuses to interact with others.
C.
The client is unable to feel any pleasure.
D.
The client has maxed-out charge cards and exhibits promiscuous behaviors.

D

51

A client with a history of suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse’s priority at this time?

A.
Give the client off-unit privileges as positive reinforcement.
B.
Encourage the client to share mood improvement in group.
C.
Increase the level of this client’s suicide precautions.
D.
Request that the psychiatrist reevaluate the current medication protocol.

C

52

A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which lab value would potentially rule out this diagnosis?

A.
Thyroid-stimulating hormone (TSH) level of 0.25 U/mL
B.
Potassium (K+) level of 4.2 mEq/L
C.
Sodium (Na+) level of 140 mEq/L
D.
Calcium (Ca2+) level of 9.5 mg/dL

A

53

A depressed client reports a history of divorce, job loss, family estrangement, and cocaine abuse to a nurse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?

A.
According to psychoanalytic theory, depression is a result of anger turned inward.
B.
According to object-loss theory, depression is a result of abandonment.
C.
According to learning theory, depression is a result of repeated failures.
D.
According to cognitive theory, depression is a result of negative perceptions.

C

54

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder?

A.
The attention during the assessment is beneficial in decreasing social isolation.
B.
Depression can generate somatic symptoms that can mask actual physical disorders.
C.
Physical health complications are likely to arise from antidepressant therapy.
D.
Depressed clients avoid addressing physical health and ignore medical problems.

B

55

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in children and adolescents?

A.
Paroxetine (Paxil)
B.
Sertraline (Zoloft)
C.
Citalopram (Celexa)
D.
Fluoxetine (Prozac)

D

56

A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam?

A.
To rule out bipolar disorder.
B.
To rule out schizophrenia.
C.
To rule out senile dementia.
D.
To rule out a personality disorder.

C

57

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client’s safety upon discharge?

A.
Provide a 6-month supply of Elavil to ensure long-term compliance.
B.
Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.
C.
Provide pill dispenser as a memory aid.
D.
Provide education regarding the avoidance of foods containing tyramine.

B

58

An older client has recently been prescribed sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?

A.
Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs).
B.
Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI).
C.
Serotonin syndrome possibly caused by ingestion of an SSRI and an MAOI.
D.
Serotonin syndrome possibly caused by ingestion of two different SSRIs.

D

59

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing response?

A.
“This combination of drugs can lead to delirium tremens.”
B.
“A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.”
C.
“That’s a good idea. There have been good results with the combination of these two drugs.”
D.
“The only disadvantage would be the exorbitant cost of the MAOI.”

B

60

A psychiatrist prescribes a monoamine oxidase inhibitor for a client. Which foods should the nurse teach the client to avoid?

A.
Pepperoni pizza and red wine
B.
Bagels with cream cheese and tea
C.
Apple pie and coffee
D.
Potato chips and diet cola

A

61

A highly agitated client paces the unit and states, “I could buy and sell this place.” The client’s mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client’s behavior?

A.
“Rates mood 8/10. Exhibiting looseness of association. Euphoric.”
B.
“Mood euthymic. Exhibiting magical thinking. Restless.”
C.
“Mood labile. Exhibiting delusions of reference. Hyperactive.”
D.
“Agitated and pacing. Exhibiting grandiosity. Mood labile.”

D

62

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?

A.
Knowledge deficit R/T bipolar disorder AEB concern about symptoms.
B.
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss.
C.
Risk for suicide R/T powerlessness AEB insomnia and anorexia.
D.
Altered sleep patterns R/T mania AEB insomnia for the past 3 nights.

B

63

A nurse is planning care for a client diagnosed with bipolar disorder: manic phase. In which order should the nurse prioritize the client outcomes in the exhibit?

Client Outcomes:
1. Maintains nutritional status.
2. Interacts appropriately with peers.
3. Remains free from injury.
4. Sleeps 6 to 8 hours a night.

A. 2, 1, 3, 4
B. 4, 1, 2, 3
C. 3, 1, 4, 2
D. 1, 4, 2, 3

C

64

A client diagnosed with bipolar disorder: depressive phase intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?

A.
Risk for suicide R/T hopelessness.
B.
Anxiety: severe R/T hyperactivity.
C.
Imbalanced nutrition: less than body requirements R/T refusal to eat.
D.
Dysfunctional grieving R/T loss of employment.

A

65

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate due to excessive weight gain. In order to increase compliance, which medication should a nurse anticipate that a physician will prescribe?

A.
Sertraline (Zoloft)
B.
Valproic acid (Depakote)
C.
Trazodone (Desyrel)
D.
Paroxetine (Paxil)

B

66

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa order. Which is the appropriate nursing response?

A.
“Zyprexa in combination with Eskalith cures manic symptoms.”
B.
“Zyprexa prevents extrapyramidal side effects.”
C.
“Zyprexa ensures a good night’s sleep.”
D.
“Zyprexa calms hyperactivity until the Eskalith takes effect.”

D

67

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?

A.
“That’s strange. Weight loss is the typical pattern.”
B.
“What have you been eating? Weight gain is not usually associated with lithium.”
C.
“Weight gain is a common, but troubling, side effect.”
D.
“Weight gain only occurs during the first month of treatment with this drug.”

C

68

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?

A.
“This disorder is more prevalent in the lower socioeconomic groups.”
B.
“This disorder is more prevalent in the higher socioeconomic groups.”
C.
“This disorder is equally prevalent in all socioeconomic groups.”
D.
“This disorder’s prevalence cannot be evaluated based on socioeconomic groups.”

B

69

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithane) for 1 year. The client presents in an emergency department with a temperature of 101?F (38?C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?

A.
Symptoms indicate consumption of foods high in tyramine.
B.
Symptoms indicate lithium carbonate discontinuation syndrome.
C.
Symptoms indicate the development of lithium carbonate tolerance.
D.
Symptoms indicate lithium carbonate toxicity.

D

70

What tool should a nurse utilize to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?

A.
“Risky Activity” tool
B.
“FIND” tool
C.
“Consensus Committee” tool
D.
“Monotherapy” tool

B

71

A client diagnosed with bipolar disorder weighs 220 lb. A physician orders lamotrigine (Lamictal) 10 mg/kg/day to a maximum of 400 mg/day for mood stabilization. Which is a true statement about this medication order?

A.
This calculated dosage is within the recommended dosage range.
B.
This calculated dosage is lower than the recommended dosage range.
C.
This calculated dosage is more than twice the recommended dosage range.
D.
This calculated dosage is four times higher than the recommended dosage range.

C

72

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?

A.
“Treatment is compromised when clients can’t sleep.”
B.
“Treatment is compromised when irritability interferes with social interactions.”
C.
“Treatment is compromised when clients have no insight into their problems.”
D.
“Treatment is compromised when clients choose not to take their medications.”

D

73

A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 lb by the end of the week?”

A.
Provide client with high-calorie finger foods throughout the day.
B.
Accompany client to cafeteria to encourage adequate dietary consumption.
C.
Initiate total parenteral nutrition to meet dietary needs.
D.
Teach the importance of a varied diet to meet nutritional needs.

A

74

A nursing instructor is teaching about specific phobias. Which student statement should indicate to the instructor that learning has occurred?

A.
“These clients recognize that their fear is excessive and seek treatment to promote change.”
B.
“These clients have a panic level of fear that is overwhelming and unreasonable.”
C.
“These clients experience symptoms that mirror a cerebrovascular accident (CVA).”
D.
“These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.”

B

75

A client has a history of excessive fear of water. What is the term that a nurse should use to describe the specific phobia, and what is the subtype of the specific phobia?

A.
Aquaphobia, a natural environment type of phobia.
B.
Aquaphobia, a situational type of phobia.
C.
Acrophobia, a natural environment type of phobia.
D.
Acrophobia, a situational type of phobia.

A

76

Which nursing statement to a client about social phobias versus schizoid personality disorder (SPD) is most accurate?

A.
“Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications.”
B.
“Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not.”
C.
“Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”
D.
“Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.”

C

77

What symptoms should a nurse use to differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?

A.
GAD is acute in nature, and panic disorder is chronic.
B.
Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
C.
Hyperventilation is a common symptom in GAD and rare in panic disorder.
D.
Depersonalization is commonly seen in panic disorder and absent in GAD.

D

78

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?

A.
Long-term treatment with diazepam (Valium).
B.
Acute symptom control with citalopram (Celexa).
C.
Long-term treatment with buspirone (BuSpar).
D.
Acute symptom control with ziprasidone (Geodon).

C

79

A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. How should a nurse explain the etiology of this fear to the spouse from a cognitive perspective?

A.
The client is unable to resolve intrapsychic conflicts, which result in projected anxiety.
B.
The client is experiencing a distorted and unrealistic appraisal of the situation.
C.
The client’s family has a history of overreaction to potential danger.
D.
The client’s high norepinephrine levels have distorted thinking.

B

80

Which symptoms should a nurse use to differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?

A.
Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.
B.
Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.
C.
Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.
D.
Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

A

81

A cab driver, stuck in traffic, suddenly is lightheaded, tremulous, diaphoretic, and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse’s first priority?

A.
Generalized anxiety disorder and a nursing diagnosis of fear.
B.
Altered sensory perception and a nursing diagnosis of panic disorder.
C.
Pain disorder and a nursing diagnosis of altered role performance.
D.
Panic disorder and a nursing diagnosis of anxiety.

D

82

A client diagnosed with panic disorder states, “When an attack happens, I feel like I am going to die.” Which is the most appropriate nursing response?

A.
“I know it’s frightening, but try to remind yourself that this will only last a short time.”
B.
“Death from a panic attack happens so infrequently that there is no need to worry.”
C.
“Most people who experience panic attacks have feelings of impending doom.”
D.
“Tell me why you think you are going to die every time you have a panic attack.”

A

83

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?

A.
“Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.”
B.
“Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.”
C.
“Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.”
D.
“Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.”

A

84

A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “Should I seek psychiatric help for my mother?” Which is an appropriate nursing response?

A.
“My mother also worries unnecessarily. I think it is part of the aging process.”
B.
“Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”
C.
“From what you have told me, you should get her to a psychiatrist as soon as possible.”
D.
“Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.”

B

85

A client is experiencing a severe panic attack. Which nursing intervention would meet this client’s physiological need?

A.
Teach deep breathing relaxation exercises.
B.
Place the client in a Trendelenburg position.
C.
Have the client breathe into a paper bag.
D.
Administer the ordered prn buspirone (BuSpar).

C

86

A college student is unable to take a final exam due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?

A.
Noncompliance R/T test taking
B.
Ineffective role performance R/T helplessness
C.
Altered coping R/T anxiety
D.
Powerlessness R/T fear

C

87

A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation to the client is most accurate?

A.
“Using your imagination, we will attempt to achieve a state of relaxation.”
B.
“Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.”
C.
“Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.”
D.
“In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.”

C

88

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

A.
The client will refrain from ritualistic behaviors during daylight hours.
B.
The client will wake early enough to complete rituals prior to breakfast.
C.
The client will participate in three unit activities by day 3.
D.
The client will substitute a productive activity for rituals by day 1.

B

89

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?

A.
“I will need scheduled blood work in order to monitor for toxic levels of this drug.”
B.
“I won’t stop taking this medication abruptly because there could be serious complications.”
C.
“I will not drink alcohol while taking this medication.”
D.
“I won’t take extra doses of this drug because I can become addicted.”

A

90

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?

A.
Sublimation
B.
Dissociation
C.
Rationalization
D.
Intellectualization

D

91

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client’s problem?

A.
Distract the client with other activities whenever ritual behaviors begin.
B.
Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
C.
Lock the room to discourage ritualistic behavior.
D.
Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

D

92

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate?

A.
High does of tricyclic medications will be required for effective treatment of OCD.
B.
Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.
C.
The dose of Luvox is low due to the side effect of daytime drowsiness.
D.
The dosage of Luvox is outside the therapeutic range and needs to be questioned.

B

93

A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What realistic goals should be included in this client’s plan of care?

A.
The client will have no flashbacks.
B.
The client will be able to feel a full range of emotions by discharge.
C.
The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
D.
The client will refrain from discussing the traumatic event.

C

94

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?

A.
History of alcohol dependence
B.
History of personality disorder
C.
History of schizophrenia
D.
History of hypertension

A

95

A client diagnosed with post traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication?

A.
Flat affect and anhedonia.
B.
Persistent anorexia and 10 lb weight loss in 3 weeks.
C.
Flashbacks of killing the enemy.
D.
Distant and guarded in relationships.

C