Mental Health Study Questions

What are the symptoms of Neuroleptic Malignant Syndrome (NMS)? Select all that apply.

A. Severe Muscle Rigidity
B. Decreased Responsiveness
C. Hyperpyrexia
D. Hypopyrexia

A. Severe Muscle Rigidity
B. Decreased Responsiveness
C. Hyperpyrexia

Which medications have a potential side effect of NMS? Select all that apply.

A. Risperdal/risperdone
B. Haldol/haloperidol
C. Prolixin/fluphenazine
D. Zyprexa/olanzapine

All are correct.

A. Risperdal/risperdone
B. Haldol/haloperidol
C. Prolixin/fluphenazine
D. Zyprexa/olanzapine

What class of medications have a potential side effect of EPS? Select all that apply.

A. Typical antipsychotic.
B. Mood stabilizers
C. Antidepressants
D. Atypical antipsychotics

A. Typical antipsychotics
D. Atypical antipsychotics

Which side effect requires transfer to a critical care unit STAT?

A. TD
B. Anticholinergic Toxicity
C. EPS
D. NMS

D. NMS

Anticholinergic Toxicity symptoms include:

A. Non-reactive pupils
B. Hot, dry, red skin
C. Dry mucus membranes
D. All of the above

D. All of the above

Which statement is true for all antidepressants?

A. All require lab work to manage dosage.
B. There is a higher risk of suicide approximately 2 weeks after starting the med.
C. All require dietary restrictions.
D. All are effective for bipolar depression.

B. There is a higher risk of suicide approximately 2 weeks after starting the med.

Which symptoms listed indicate lithium toxicity? Select all that apply.

A. ECG changes
B. Hyperactivity
C. Mental confusion
D. Hand tremors

A. ECG changes
C. Mental confusion
D. Hand tremors

When starting Tegretol (Carbamazepine) which lab value is not required to be monitored for the first 8 weeks of treatment?

A. Tegretol level
B. TSH
C. LFTs
D. Platelets

B. TSH

A common side effect for antipsychotics is orthostatic hypotension.

True or false

True

Insomnia and weight loss are common side effects for psychostimulantants.

True or false

True

A patient with borderline personality disorder has been hospitalized several times after self-injurious behavior and suicide attempts. The patient has entered dialectical behavior therapy on an outpatient basis. During therapy, the advanced practice nurse has been counseling her regarding self-harm behavior management. Today the patient called the nurse and reported “feeling empty and anxious” and wants to cut herself. Which response would best help in this situation?

A. Arrange for an emergent admit to a crisis unit.
B. Assist the pt to identify and choose a coping strategy.
C. Advise the pt to take an anxiolytic, then go to sleep.
D. Arrange for an emergent admit to an inpatient unit.

B. Assist the pt to identify and choose a coping strategy.

An 82-year-old widow with Alzheimer’s disease lives with family, which owns a catering business. During the week, the pt attends a day care center for pts with dementia. During the evenings, members of the family care for the pt. One day, the RN at the day care center notices the pt’s appearance is disheveled and that she startles easily. She has a strong odor of urine, and her hair is uncombed. When the RN escorts the pt to the bathroom, she notices bruises on her wrists and back. What most likely explains the RN’s observations?

A. The patient has developed delirium, resulting in poor hygiene and injuries.
B. The patient is being inadequately cared for, resulting in accidents.
C. The dementia is progressing, reducing self-care and increasing falls.
D. The patient is being neglected and abused within the family.

D. The patient is being neglected and abused within the family.

Several children a day are seen in the emergency department for treatment of illnesses and injuries. The situation that would create a high index of suspicion of child abuse is a child who:

A. Has perineal bruises and UTIs.
B. Displays reduced functioning at school.
C. Has repeated middle ear infections.
D. Complains of abd. cramps and upset stomach.

A. Has perineal bruises and UTIs.

The parent of a 4-year-old says, “My child moves constantly. I try to get him interested in toys, but he is easily distracted. He talks all the time and is awake every morning before I am. I enrolled him in preschool, but the teacher could not handle him.” The child’s problem meets criteria for:

A. Pervasive developmental disorder.
B. ODD
C. PTSD
D. ADHD

D. ADHD

A child with ADHD is to begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?

A. MAOIs
B. Psychostimulant drugs
C. Antipsychotic drugs
D. Anxiolytic drugs

B. Psychostimulant drugs

When assessing a 2-year-old with suspected autistic disorder, a nurse would expect:

A. High levels of anxiety when separated from the parent.
B. Hyperactivity and attention deficits.
C. Failure to develop interpersonal skills.
D. A Hx of disobedience and destructive acts.

C. Failure to develop interpersonal skills.

A 5-year-old cries and screams from the time the parents leave the child at kindergarten until picked up 6 hours later; however, this child is calm and relaxed when with the parents. The parents ask the nurse, “What should we do?” Select the nurse’s best advice.

A. “Talk with the school about withdrawing the child until maturity increases.”
B. “Send a picture of yourself to school to keep with the child.”
C. “Talk with your health care provider about a referral to a mental health clinic.”
D. “Arrange with the teacher to let the child call home at play time.”

C. “Talk with your health care provider about a referral to a mental health clinic.”

A 15-year-old was referred to the mental health clinic by juvenile court after an arrest for prostitution and assault on the mother. The teen tells the nurse, “I hate my parents. They focus all attention on my brother. He’s perfect in their eyes.” Which type of therapy might promote the greatest change in the adolescent’s behavior?

A. Art therapy
B. Family therapy
C. Play therapy
D. Bibliotherapy

B. Family therapy

Which factor places a child most at risk for development of a psychiatric disorder?

A. Developmental milestones achieved on schedule
B. Being raised by a mother with chronic major depression
C. Not being promoted to the next grade at the completion of a school year
D> Moving to three new homes over a 2-year period

B. Being raised by a mother with chronic major depression

A child known as the neighborhood bully recently set fire to a dumpster outside a supermarket. The parents report, “This event happened after our child was suspended from school for fighting.” These behaviors are most consistent with:

A. Asperger’s disorder
B. Pervasive developmental disorder
C. Conduct disorder
D. ADD

C. Conduct disorder

An adolescent acts out in disruptive ways. When this patient threatens to throw a billiard ball at another adolescent, which comment by the nurse would set limits?

A. “Attention everyone: we are all going to the craft room.”
B. “You will be taken to seclusion if you throw that ball.”
C. “Please do not lose control of your emotions.”
D. “Do not throw the ball. Put it back on the pool table.”

D. “Do not throw the ball. Put it back on the pool table.”

A female client is seen in the ED with ecchymosis of the trunk and face. Upon direct questioning by the nurse, the client admits to having been struck by her spouse. When offered information about shelters for battered women, the client declines stating, “I could never leave my husband because of my kids.” Which of the following is an appropriate nursing response?

A. Aren’t you worried about the safety of your children?
B. Can you identify the situations that provoke your husband?
C. I am concerned about your safety.
D. I wouldn’t put up with this if I were you.

C. I am concerned about your safety.

A pt admitted to the hospital with abd px and GI bleeding has a colonoscopy, and colon CA is discovered. The provider comes to the pt’s room, tells the client the Dx, discusses treatment options, and leaves. Shortly after, the nurse enters the room and the pt begins yelling at the nurse stating, “I have received lousy care here and no one cares about me.” The nurse recognizes that the client is demonstrating the defense mechanism of

A. Denial
B. Displacement
C. Regression
D. Projection

B. Displacement

Regression
Regression is a defense mechanism in which a person reverts to an earlier stage of development in attempt to reduce anxiety and conflict.

Denial
Denial is a defense mechanism in which a person refuses to accept reality and act as if the event, thought, or feeling does not exist.

Displacement
Displacement is a defense mechanism characteristic of the redirecting of thoughts, feelings, and impulses from the original object that gives rise to anxiety to a safer, more acceptable substitute.

A pt with hallucinations is admitted to the psychiatric unit. In the initial phase of establishing a therapeutic nurse pt relationship, it would be appropriate for the nurse to explore which of the following?

A. Perception of the presenting problem.
B. Description of the hallucinations
C. Feelings about hospitalization
D. Relationships with the family.

A. Perception of the presenting problem.

Description of hallucinations – appropriate for the assessment phase.

Feelings about hospitalization – appropriate for the assessment phase.

Relationship with the family – appropriate for the working phase.

As a nurse approaches a pt with schizophrenia, the client looks at the nurse and says, “Back off. Leave me alone.” The client appears tense and is pacing rapidly. Which of the following is an appropriate nursing response?

A. “I can’t leave you alone when you are this upset. Sit down, and try to relax.”
B. “Let’s go to your room, and you can tell me what is bothering you.”
C. “I will give you space as long as you control yourself. I’d like to know what is causing you to feel so tense.”
D. “I will leave you alone for a few minutes while you try to compose yourself.”

C. “I will give you space as long as you control yourself. I’d like to know what is causing you to feel so tense.”

A client in a long term care facility asks the nurse to telephone her husband and ask him if he remembered to pick up his suit at the cleaners. The nurse knows the client’s husband died five years before. Which of the following is an appropriate nursing response?

A. “How long were you married to your husband?”
B. “Remember? Your husband died five years ago.”
C. “You’ve forgotten that your husband is dead, haven’t you?”
D. “You miss your husband a lot, don’t you?”

D. “You miss your husband a lot, don’t you?”

The nurse asks a client who is suicidal to make a safety contract. The client states to the nurse, “I cannot make a safety contract, because I can’t promise that I will not harm myself.” In the nurse’s plan of care, which of the following initial actions is best to ensure this client’s safety when implementing the plan of care?

A. Lock the doors to the unit and secure all windows so they cannot be opened.
B. Remove belts, glass objects, and sharp instruments from the client’s environment.
C. Have a staff member stay with the client at all times.
D. Provide a relaxed and accepting environment to develop trust.

C. Have a staff member stay with the client at all times.

The RN in the oncology unit provides support to the parents of a child newly diagnosed with a glioblastoma tumor of the brain. In planning care, the RN understands the parents’ initial reaction to a potentially terminal illness in their child is:

A. Denial and disbelief
B. Fear and anxiety
C. Anger and guilt
D. Depression

A. Denial and disbelief

The spouse of a chronic alcoholic client says to the nurse, “I told my husband I would leave if he did not get into treatment. Now that he is here, I feel differently. What can I do to help him?” Which of the following is a therapeutic nursing response?

A. “You should attend an Al-Anon meeting. The group can teach you how best to help him stay sober.”
B. “You have already done a great deal by getting him here. Now, it is up to him.”
C. “Are you feeling some responsibility for his drinking?”
D. “Tell me more about the kind of help you feel you are able to provide at this time.”

D. “Tell me more about the kind of help you feel you are able to provide at this time.”

A nurse is admitting an adolescent female to the psychiatric unit for observation related to clinical depression. After completing the admission assessment, the nurse should give greatest priority to which of the following finding?

A. The client frequently argues with her parents.
B. The client is getting C’s in school because she is absent a lot.
C. The client smokes half a pack of cigarettes per day.
D. The client gave her favorite necklace to her best friend.

D. The client gave her favorite necklace to her best friend.

A nurse is caring for a client admitted for depression 1 week ago who was started on paroxetine (Paxil) at the time of admission. The client states to the nurse, “My family would be better off without me.” Which of the following is an appropriate therapeutic response by the nurse?

A. “I do not feel that you really believe that.”
B. “Everyone feels this way when depressed.”
C. “You sound upset. Are you thinking of hurting yourself?”
D. “You’ll feel better once your medications start working.”

C. “You sound upset. Are you thinking of hurting yourself?”

An RN is caring for a pt diagnosed with dementia. She should understand that the goal of reminiscence therapy in long-term care facilities is to

A. Share memories of past experiences and events.
B. Reorient pts with cognitive problems.
C. Stimulate and encourage social participation.
D. Resolve emotional problems

A. Share memories of past experiences and events.

A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. At 3:00 AM, the client runs to the nurse’s station and demands to see the therapist immediately. Which of the following responses by the nurse is appropriate?

A. “You are being unreasonable, and I will not call your therapist at 3:00 in the morning.”
B. “Why do you need to see your therapist tonight?”
C. “Calm down, go back to your room, and I’ll try to get in touch with your therapist right away.”
D. “You must be very upset about something to want to see your therapist in the middle of the night.”

D. “You must be very upset about something to want to see your therapist in the middle of the night.”

While working with a pt, an RN unconsciously attributes negative feelings to the pt and becomes antagonistic toward her. The RN is demonstrating which of the following?

A. Reciprocity
B. Countertransference
C. Transference
D. Self-evaluation

B. Countertransference

An RN caring for a pt diagnosed with disorganized schizophrenia. The pt does not returne a visitor’s greeting and instead lies down on the bed and curls up in the fetal position. Which of the following defense mechanisms is the pt exhibiting?

A. Regression
B. Symbolization
C. Repression
D. Fixation

A. Regression

A client who is bipolar states to the psychiatric nurse in the mental health outreach clinic, “I no longer take my medication because I like to feel manic.” Which of the following is an appropriate therapeutic nursing response?

A. “You may feel good now, but what about when you get depressed?”
B. “What do you like about being manic?”
C. “You feel better when you don’t take your medication?”
D. “You really should follow your provider’s orders if you want to be well.”

C. “You feel better when you don’t take your medication?”

An RN’s neighbor has just found out that her teenage child has died in a MVA. The neighbor is crying inconsolably. Which of the following is an appropriate therapeutic nursing response?

A. Suggest calling her spouse for her.
B. Ask her if there is anything that can be done for her.
C. Sit silently with her while she cries.
D. Share feelings with her regarding the recent loss of a sibling.

C. Sit silently with her while she cries.

A client is admitted to the psychiatric unit for depression. The nurse observes an improvement in the client’s grooming when the client comes to breakfast freshly bathed wearing clean clothes and with combed hair. Which of the following is an appropriate therapeutic response by the nurse?

A. “You must be getting better. You look great!”
B. “Let’s go put some make-up on to make you look even better.”
C. Why did you get all dressed up today? Is it a special occasion?
D. “You look nice after your bath and shampoo.”

D. “You look nice after your bath and shampoo.”

A client is admitted to the psychiatric unit following treatment in the emergency room for an intentional overdose ingestion. As the nurse performs the admission assessment, the client says, “Why would you want to waste your time on a worthless person like me?” Which of the following is a therapeutic nursing response?

A “Let’s discuss your feelings more after we finish admitting you.”
B. “I don’t think talking to you is a waste of time.”
C. “Why do you feel the way you do?”
D. “I think you are worthwhile, and I want to talk to you.”

D. “I think you are worthwhile, and I want to talk to you.”

The nurse working with a depressed client notes that the client has not come to breakfast and finds the client still in bed in a nightshirt. The client tells the nurse, “I’m too sick to bother. Leave me alone and go help someone else who is worth your time.” Which of the following is an appropriate response by the nurse?

A. “Everyone feels that way when they first start treatment.”
B. “You sound very discouraged and hopeless today.”
C. “You’ll feel so much better once you get up and into your own clothes.”
D. “Why do you say that you are too sick to bother?”

B. “You sound very discouraged and hopeless today.”

A pt has been diagnosed with anorexia nervosa. The RN would anticipate that this pt will display which of the following?

A. Increased sensitivity to other’s needs.
B. A poor sense of self-identity
C. Exaggerated feelings of guilt.
D. Excessive amounts of fear and suspicion.

B. A poor sense of self-identity

A nurse should assess that the client with the highest potential for suicide is the depressed client who states which of the following?

A. “At breakfast today everyone was talking about me. They were all staring at me.”
B “I don’t feel like going to group therapy today. I don’t want to be with other people.”
C. “I have it all figured out. Everything is going to be okay now.”
D. “I don’t feel like showering or eating. I’d rather just stay in bed today.”
c. “I have it all figured out. Everything is going to be okay now.”

C. “I have it all figured out. Everything is going to be okay now.”

A parent brings an 18 mon old child to the ED. The child has sustained a fractured L femur. Which of the following statements by the parent might make the RN suspect child abuse?

A. “My child is so active and gets into everything.”
B. “My child was riding a bicycle and got the R foot caught in the spokes.”
C. “My child slipped out of the high chair because the strap was too loose.”
D. “My child climbed up on a chair and fell down.”

B. “My child was riding a bicycle and got the R foot caught in the spokes.”

The RN is working in a busy peds ED. In which of the following cases should the RN maintain a high index of suspicion of physical child abuse?

A. A 14 mon. old who is reportedly “clumsy” with many bruises on bony prominences in various stages of healing.
B. A 9 mon. old who reportedly nearly drowned after climbing into the tub and turning on the water.
C. A 6 yr old with a tib/fib fracture, which reportedly occurred while riding a bicycle.
D. A 3 yr old with 15% burns in a splash pattern over the face and chest reportedly sustained when a tablecloth was pulled, spilling a teapot.

B. A 9 mon. old who reportedly nearly drowned after climbing into the tub and turning on the water.

An RN is caring for a pt diagnosed with borderline personality disorder. The pt becomes attached to one of the RNs and refuses to talk with any of the other staff members. The pt says the other staff members are abusive and untrustworthy. The pt is using which of the following defense mechanisms?

A. Splitting
B. Reaction formation
C. Projection
D. Idealization

A. Splitting.

Splitting
Splitting is a defense mechanism in which a person relates to others as if they are all good or all bad.

Reaction formation
Reaction formation is a defense mechanism where a person is expressing an attitude that is the direct opposite of one’s true feelings and wishes.

Projection
Projection is a defense mechanism in which a person denies responsibility for one’s internal feelings, thoughts, or impulses by attributing them to other persons.

Idealization
Idealization is a defense mechanism in which a person overestimates admired qualities of another person.

A nurse receives a call on a crisis intervention hotline from a client who threatens to commit suicide. Which would be the most important question for the nurse to ask?

A. “Have you attempted suicide before?”
B. “What happened to make you so desperate?”
C. “How will you carry out your plan?”
D. “What will you accomplish by taking your life?”

C. “How will you carry out your plan?”

An RN should recognize that MRI procedures are generally contraindicated for pts who have a fear of which of the following?

A. Closed spaces
B. Dark places
C. Immobilization
D. Needles

A. Closed spaces.

A college junior comes to the campus health service with reports of severe epigastric distress, and the RN discovers the pt has suffered from severe bulimia since freshman year. The pt tells the RN, “I know my eating binges and vomiting are not normal, but I cannot control it.” Which of the following is an appropriate therapeutic nursing response?

A. “Is there any pattern to your eating binges and vomiting?”
B. “Do you have a family Hx of eating disorders?”
C. “You are feeling helpless about changing this behavior?”
D. “You must stop. You are destroying your health.”

C. “You are feeling helpless about changing this behavior?”

A pt diagnosed with borderline personality disorder has become attached to one of the RNs who calls in sick one day. When given this news, the pt breaks a glass bottle and uses it to self-inflict a deep scratch. After providing first aid, which of the following is a therapeutic nursing action in relation to the pt’s behavior?

A. Permit the pt to remain alone.
B. Ignore the pt’s behavior.
C. Telephone the pt’s favorite RN to talk with the pt.
D. Help the pt verbalize her feelings and reasons for the acting-out behavior.

D. Help the pt verbalize her feelings and reasons for the acting-out behavior.

A client is hospitalized with schizophrenia. During a conversation with the nurse, the client seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which statement by the nurse would be appropriate at this time?

A. “Did I say something wrong that made you feel tense?”
B. “Do you often feel tense when you are talking to a health care provider?”
C. “What were we discussing when you began to feel uncomfortable?”
D. “I sometimes feel tense, too, when I am talking to a stranger.”

C. “What were we discussing when you began to feel uncomfortable?”

The RN should document that the pt is experiencing mild anxiety when the RN observes which of the following?

A. The pt is extremely alert.
B. The pt c/o a stomach ache.
C. The pt paces in the day room.
D. The pt has dilated pupils.

A. The pt is extremely alert.

A pt is admitting to the detox center for alcohol addiction. On the day after admission, the pt develops hand tremors and asks the RN about them. Which of the following is an appropriate nursing response?

A. “They are permanent changes because the alcohol has destroyed your nerves.”
B. “They will persist for a few days now that you are not drinking.”
C. “This is unusual. We will have to notify your provider immediately.”
D. “These are very typical of the seizures that are associated with alcohol withdrawal.”

B. “They will persist for a few days now that you are not drinking.”

A widow is brought to the clinic by her adult son, who found her at home crying. She said that she could not go on alone. He tells the RN that when his father died 6 mons ago, the family was amazed at his mother’s fortitude during and immediately after the funeral. She did not cry or seem unduly upset. The RN recognizes that his mother had previously dealt with her husband’s death by using which defense mechanism?

A. Denial
B. Repression
C. Introjection
D. Sublimation

A. Denial

Introjection
Introjection is a defense mechanism in which a person adopts characteristics of a loved one.

Sublimation
Sublimation is a defense mechanism in which a person converts unacceptable drives into socially sanctioned activities.

Which of the following is an important short term goal for an RN to plan with a suicidal pt?

A. Develop more adaptive family relationships
B. Sign a contract pledging not to act on suicide plans
C. Explore the motivating factors for suicide
D. No longer verbalize thoughts or feelings as they relate to suicide.

B. Sign a contract pledging not to act on suicide plans

Physical safety is priority. The RN should prevent the pt from carrying out suicide.

A pt with dementia says to the RN, “Everyone wants to kill me.” Which of the following statements is an appropriate nursing response?

A. “Why do you think that someone would want to kill you?”
B. “You are frightened. This is a hospital and we are here to help.”
C. “Don’t worry. No one here wants to kill you.”
D. “Who in particular do you think wants to kill you?”

B. “You are frightened. This is a hospital and we are here to help.”

While taking a health Hx from a pt in the outpatient mental health clinic, an RN observes that the pt is persistent in making personal inquiries. Which of the following is the most therapeutic response?

A. Explain to the pt that this time is for him.
B. Introduce an unrelated topic to distract the pt.
C. Accept this behavior as a sign of the pt developing trust.
D. Relate to the pt that you do not wish to engage in this conversation.

A. Explain to the pt that this time is for him.

An RN is caring for a pt who is scheduled for a cardiac cath. When arriving for the procedure, the pt reports butterflies in the stomach, a sense of restlessness, urinary frequency, and some difficulty concentrating while driving to the hospital. The admitting RN should assess the pt’s anxiety level as which of the following?

A. Moderate
B. Mild
C. Severe
D. Panic

A. Moderate

A client diagnosed with schizophrenia says to the nurse, “They lied about me and are trying to poison my food.” Which of the following is a therapeutic nursing response?

A. “Tell me who would do such things to you?”
B. “You are mistaken. Nobody has told lies about you or tried to poison you.”
C. “Tell me more about your concerns about being poisoned.”
D. “You’re having very frightening thoughts.”

D. “You’re having very frightening thoughts.”

Focus on the fear, which is real, rather than the beliefs, which are not real.

An RN on a mental health care unit is providing care for a pt diagnosed with schizophrenia. The pt is experiencing delusional thinking. Which of the following defense mechanisms is the pt using when making delusional statements?

A. Projection
B. Dissociation
C. Displacement
D. Regression

A. Projection

Dissociation
Dissociation is a defense mechanism in which a pt detaches emotional or behavioral processes from usual conscious behavior.

An RN is caring for a pt experiencing anxiety at the panic level. Which of the following should be the RN’s primary goal?

A. Identify the cause of the anxiety.
B. Reduce the pt’s immediate anxiety.
C. Investigate the situation that preceeded the attack.
D. Explain the physical manifestations of anxiety to the pt.

B. Reduce the pt’s immediate anxiety.

A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following side effects should the nurse report promptly to the client’s provider?

A. Fine hand tremor
B. Constipation
C. Drowsiness
D. Urinary retention

D. Urinary retention

A potentially serious side effect. In addition to monitoring the client’s I&O, the nurse should check for abd distention, hold the next dose of the antidepressant, and report the client’s condition to the provider. Urinary retention can lead to bladder infection and loss of bladder tone.

A client is hospitalized for a OCD with recurring thoughts of mouth odors that are offensive to others. The client also has mouth care rituals that occupy a good deal of the client’s waking hours and caused him to be fired from his last job. The nurse understands that these manifestations most likely represent which of the following?

A. Method of reducing anxiety
B. Form of manipulation to avoid work
C. Strategy to get attention
D. Rationalization for avoiding social contact.

A. Method of reducing anxiety

A nurse asks an older adult client, “Did you have any visitors, yesterday?” The client responds, “Yes, several members of my church choir came to see me.” The nurse knows that only the client’s child visited the day before. Which of the following is the client demonstrating?

A. Illusion
B. Confabulation
C. Delusion
D. Projection

A. Confabulation

Delusion
A false, fixed belief. Delusional thinking is most often associated with schizophrenia and other psychotic disorders.

Illusion
A misinterpretation of a real sensory experience. It is a misperception and is not associated with a memory problem.

Confabulation
Filling in gaps in memory by fabrication. The client will make up responses that are inaccurate but sound appropriate. It is done to avoid the embarrassment about memory loss.

A nurse is caring for a client who is experiencing the early phase of alcohol withdrawal. Which of the following should be the primary focus of nursing care?

A. Education about alcohol abuse and treatment
B. Assessing coping skills
C. Confronting the use of denial and other defense mechanisms
D. Rest and nutrition.

D. Rest and nutrition

Early phase = detox. The RN should focus on the client’s physical and medical needs.

An eyewitness to a violent crime is unable to give police an account of the crime and complains of blindness and a severe headache when asked to view “mug shots.” Which of the following defense mechanisms is the client using?
A. Rationalization
B. Denial
C. Conversion
D. Regression
C. Conversion

Rationalization
A defense mechanism in which a person offers a socially acceptable or logical explation for otherwise unacceptable impulses

An ED RN is assessing a pt for cocaine intoxication. The RN should know that which of the following is associated with cocaine intoxication?

A. Pinpoint pupils
B. Drowsiness
C. Nystagmus
D. Paranoia

D. Paranoia

A nurse is caring for a client in the day treatment program who is diagnosed with hypochondriasis. The client constantly reports physical problems, and the other clients in the unit are beginning to avoid the client. Which of the following should be the nurse’s primary intervention to decrease social isolation?

A. Ask other clients to be more sympathetic of complaining client.
B. Encourage the client to participate in group diversional activities.
C. Ask the client to stop talking about physical complaints.
D. Encourage the client to rest alone when upset.

B. Encourage the client to participate in group diversional activities.

The admitting nurse asks a client what factors, such as recent life changes, have contributed to the need for hospitalization. The client replies, “Change…change the range, manage the change.” The nurse should recognize this response as an example of which of the following?

A. Flight of ideas
B. Echolalia
C. Perseveration
D. Clanging

D. Clanging

Clanging
Speech in which sounds, rather than conceptual relationships, influence word choice. Commonly associated with schizophrenia and mania.

Perseveration
The persistent repetition of words or ideas to an excessive point so that once an individual uses a particular word is recurs. Commonly associated with organic mental disorders or schizophrenia.

Echolalia
Repetition or echoing of the words or phrases said by others.

Flight of ideas
A nearly continuous flow of accelerated speech with abrupt changes from topic to topic before the original topic is completed. Common in manic episodes.

A client is receiving lorazepam (Ativan) for anxiety. In reviewing the client’s discharge plans, the nurse should emphasize that lorazepam.

A. Should not be taken during pregnancy.
B. Must be discontinued by gradual tapering over time.
C. Is contraindicated for clients with asthma.
D. Is a safe medication with no known adverse effects.

B. Must be discontinued by gradual tapering over time.

A nurse is planning a menu for a client with bipolar disorder who was admitted for an acute manic episode. Which of the following is an appropriate meal for this client?

A. Spaghetti and meat balls, salad, banana.
B. Beef and vegetable stew, bread, vanilla pudding.
C. Chicken nuggets, ear of corn, apple
D. Fish fillets, stewed tomatoes, cake

C. Chicken nuggets, ear of corn, apple

A client on the psychiatric unit is confirmed to have hypochondriacal disorder. The nurse is aware that the client is likely to exhibit which of the following?

A. Preoccupation with physical health.
B. Loss of a physical function without pathology
C. Attention seeking by deliberately causing harm to his child
D. Ritualistic handwashing as a way to avoid contact with germs.

A. Preoccupation with physical health.

A pt is taking a tricyclic antidepressant is seen at the clinic. The pt reports experiencing several side effects from the medication. Which of the following is the most common side effect associated with tricyclic antidepressants?

A. Skin rashes
B. Excessive sweating
C. Drowsiness
D. Muscle breakdown

C. Drowsiness

An RN is providing medication teaching to a client who is prescribed the monoamine oxidase inhibitor (MAOI) Phenelzine (Nardil). The nurse should caution the client against concurrent use of which of the following over the counter medications?

A. Acetaminophen (Tylenol)
B. Ranitidine (Zantac)
C. Benztropine (Cogentin)
D. Pseudoephedrine (Sudafed)

D. Pseudoephedrine (Sudafed)

A nurse plans to teach important information about the anxiolytic agent diazepam (Valium) to a client for whom it has just been prescribed. The nurse should include in the teaching plan which of the following?

A. Side effects include insomnia and seizures
B. Valium can be habit forming.
C. This medication is administered solely by mouth
D. It takes 2 to 3 weeks to reach full therapeutic effect.

B. Valium can be habit forming.

During this process, the nurse should watch for which of the following early manifestations of tardive dyskinesia?

A. Jerky, choreiform movements of the UE’s
B. Slow, involuntary athetoid movement of the arms and legs
C. Involuntary grimacing, lip smacking, and tongue protrusion.
D. Tonic contractions of the neck and back.

C. Involuntary grimacing, lip smacking, and tongue protrusion.

A nurse can evaluate the progress of a client with agoraphobia as having improved when the client is able to attend which of the following?

A. A unit picnic in a local park
B. Occupational therapy
C. The hospital gift shop
D. Daily group therapy

A. A unit picnic in a local park

A nurse is caring for a client diagnosed with schizophrenia. The client spends a great deal time rhyming syllables such as, “Me, see, bee, tree.” The nurse should recognize that the client is demonstrating use of which of the following?

A. Clang association
B. Echolalia
C. Pressured speech
D. Word salad.

A. Clang association

An emergency room nurse is admitting a client who is complaining of CP and dyspnea. The client is also flushed and perspiring profusely, screaming, “I am going to die! This is it! I am having a heart attack!” The medical exam and lab work are negative. The client is diagnosed with anxiety. The nurse should assess the client’s level of anxiety to be which of the following?

A. Moderate
B. Panic
C. Severe
D. Mild

B. Panic

A nurse is providing discharge instructions for a client who is on Lithium (Lithane). The nurse should instruct that which of the following can precipitate Lithium toxicity?

A. Increasing sodium intake
B. Mild exercise
C. Fasting
D. Carbamazepine (Tegretol) therapy

C. Fasting

A manic client tells the nurse that his lastest computer project is revolutionizing the industry. He also states, “IBM and Apple are both going under because their products cannot compete with mine.” In choosing how to respond, the nurse is best guided by the knowledge that this statement represents which of the following?
A. An illusion
B. Paranoia
C. Confabulation
D. Grandiose delusion
D. Grandiose delusion

What information about diet should a nurse give all clients taking lithium?

A. Sodium and fluid intake should be increased
B. Fluid intake should not exceed 100mL per day
C. Sodium intake should be restricted to 1200mg per day.
D. An adequate daily intake of sodium and fluids should be maintained.

D. An adequate daily intake of sodium and fluids should be maintained.

A nurse is caring for a client diagnosed with a severe anxiety disorder. The client is in a state of panic in the dayroom. Which of the following actions should the nurse implement initially for the client?

A. Speak in a calm manner.
B. Leave the client alone regain control
C. Encourage the client to express her feelings.
D. Ask the client to describe what occurred before the panic.

A. Speak in a calm manner.

A nurse should understand that clients who are diagnosed with agoraphobia display which defense mechanism?
A. Displacement
B. Isolation
C. Denial
D. Undoing
A. Displacement

A nurse is caring for a client who was admitted to the psychiatric hospital for an evaluation. The client has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes very anxious and must quickly return inside. The nurse identifies the problem as which of the following?

A. Agoraphobia
B. Conversion disorder
C. Panic disorder
D. OCD

A. Agoraphobia

Which of the following is the best approach for a nurse to take initially with a client who is experiencing severe anxiety?

A. Move the client to a calm, non-stimulating environment.
B. Encourage the expression of feelings
C. Lower the client’s level of anxiety by offering medication.
D. Suggest the client engage in some automatic behavior, such as pacing, to reduce anxiety levels.

A. Move the client to a calm, non-stimulating environment.

A nurse should understand that a common side effect of benzodiazepine antianxiety medications is which of the following?

A. Seizures
B. Dizziness
C. Flatulence
D. Insomnia

B. Dizziness

A nurse is caring for a client who has been diagnosed with bipolar disorder. The client is pregnant. Which of the following medications is appropriate for this client to take?

A. Carbamazepine (Tegretol)
B. Valproic acid (Depakote)
C. Paroxetine (Paxil)
D. Lithium (Lithane)

C. Paroxetine (Paxil)

Four days after admission, a client who is taking haloperidol (Haldol) is pacing up and down the hallway. The nurse observes and assesses further by asking how the client feels. The client replies “I am very restless and can’t seem to sit still.” The nurse should understand that the client is experiencing which of the following extrapyramidal side effects?

A. dystonia
B. parkinsonism
C. tardive dyskinesia
D. akathisia

D. akathisia

Dystonia
EPS characterized by muscle spasms

Akathisia
EPS characterized by a pt’s complain of a sense of inner restlessness and observable behaviors like pacing and fidgeting.

A nurse is caring for a client diagnosed with OCD. Initially, which of the following actions should the nurse consider in dealing with the client’s ritualistic behaviors?

A. Plan the client’s schedule to allow extra time to perform the rituals to keep anxiety within manageable levels.
B. Set strict limits on the behaviors so the client can better conform to the unit rules and schedules.
C. Isolate the client for a period of time to lower anxiety about offending others.
D. Confront the client about the senseless nature of the ritualistic behaviors.

A. Plan the client’s schedule to allow extra time to perform the rituals to keep anxiety within manageable levels.

A client is admitted for the third time to a psychiatric hospital with a diagnosis of schizophrenia. During the admission procedure, the nurse notices that the client’s appearance is unkempt, and the client seems to be actively hallucinating. Which of the following should be the nurse’s priority nursing assessment?

A. Perception of reality
B. Ability to follow directions
C. Physical needs
D. Mental status

C. Physical needs

A client with a history of psychosis is prescribed quetiapine fumarate (Seroquel) 150 mg four times a day. Which of the following statements should the nurse include when providing the client education about this medication?

A. “You will need to be careful of exposure to the sun and wear a sunscreen when outdoors.”
B. “While you are taking Seroquel, you will need to have weekly blood counts.”
C. “Weight gain is less common with Seroquel than with other atypical antipsychotics.”
D. “Seroquel is effective in managing rapid-cycling manic episodes.”

C. “Weight gain is less common with Seroquel than with other atypical antipsychotics.”

A client is admitted with a diagnosis of acute schizophrenia. The client is started on chlorpromazine (Thorazine) 100 mg 3 times a day for agitation. When the client is calmer, the nurse begins client teaching about the medication. The nurse knows it is appropriate to state which of the following?

A. “Thorazine is an antipsychotic that can cure your disorder.”
B. “Thorazine is a sedative that helps to calm you down.”
C. “Thorazine will help to control the symptoms of your illness.”
D. “Thorazine controls the side effects of antipsychotic drugs.”

C. “Thorazine will help to control the symptoms of your illness.”

A nurse is caring for a client diagnosed with somatization disorder. The nurse should understand that a client with this disorder will use which of the following defense mechanism?

A. Displacement
B. Repression
C. Undoing
D. Suppression

B. Repression

A nurse is caring for a client who has obsessive compulsive disorder. The client engages in repeated hand washing. Which of the following is the purpose of the client’s behavior?

A. Relief of anxiety
B. Gaining attention
C. Avoiding daily responsibilities
D. Controlling a phobia for germs.

A. Relief of anxiety

A nurse is administering the neuroleptic medication thioridazine hydrochloride (Mellaril) 150 mg four times a day. The client reports hand tremors, drooling, and restlessness. Which of the following is an appropriate nursing action?

A. Chart observations and reassure the client that these manifestations are normal.
B. Administer diazepam (Valium) 5mg PO (ordered PRN).
C. Encourage deep breathing and relaxation
D. Administer benztropine Mesylate (Cogentin) 1mg PO (ordered PRN).

D. Administer benztropine Mesylate (Cogentin) 1mg PO (ordered PRN).

A nurse is planning care for a client with panic disorder who is taking alprazolam (Xanax) 0.25 mg t.i.d.. Which of the following instructions should the nurse give the client?

A. “You should increase your fluid intake to prevent dry mouth.”
B. “You should take this medication with food to prevent GI upset.”
C. “You will need to watch your caloric intake to prevent weight gain.”
D. “You will have to read food labels careful to eliminate tyramine from your diet.”

A. “You should increase your fluid intake to prevent dry mouth.”

A nurse in the outpatient mental health clinic is interviewing a client with schizophrenia who appears to be experiencing auditory hallucinations. Which of the following should be the nurse’s initial action?

A. Teach the client strategies to decrease the hallucinations.
B. Check that the client is on antipsychotic medications.
C. Establish rapport with the client.
D. Explore what the voices are saying to the client.

C. Establish rapport with the client.

Which of the following defense mechanisms does a client with obsessive compulsive disorder exhibit when performing rituals?

A. Projection
B. Undoing
C. Rationalization
D. Sublimation

B. Undoing

Social vs therapeutic relationship
Social = focus on mutual needs

Therapeutic = focus on patient’s problem and needs

Positive symptoms
Manifestation of things that are not normally present

Examples:
– Hallucinations (alterations in speech)
– Delusions (bizarre behavior; walking backward)

Negative symptoms
Absence of things that are normally present

Examples:
Affect – blunted or flat
Alogia – poverty of thought or speech patient mumbles
Anergia – lack of energy
Anhedonia – lack of pleasure or joy
Avolition – lack of motivation

A client who has Alzheimer’s disease becomes agitated and combative when a nurse approaches her for morning care. Which of the following is an appropriate nursing action?

A. Remain calm and talk quietly to the client.
B. Obtain assistance to restrain the client for safety.
C. Firmly state to the client that morning care will be performed.
D. Call the provider to request a prescription for a sedative medication.

A. Remain calm and talk quietly to the client.

An RN should recognize that which of the following is a typical characteristic of pts with anorexia nervosa?

A. Poor school performance
B. Relentless exercise
C Honesty in eating habits
D. Lack of self-control

B. Relentless exercise

An elderly client with Alzheimer’s disease has begun to strike out at staff members when they try to assist the client to bed at night. In addition, the staff members report that the client is awake and restless most of the night. After further assessment, the nurse decides to contact the provider for a medication order. Which of the following meds should the nurse anticipate that the provider will prescribe?

A. Lorazepam (Ativan) PRN
B. Hydroxyzine (Vistaril) twice daily
C. Chlorpromazine (Thorazine) TID
D. Haloperidol (Haldol) at HS

A. Lorazepam (Ativan) PRN

A nurse should question an order if a provider has prescribed a benzodiazepine for a client for the treatment of which of the following?

A. Skeletal muscle injuries
B. Status epilepticus
C. Chronic pain syndrome
D. Insomnia

C. Chronic pain syndrome

A male client is admitted to the psychiatric hospital under court order with a diagnosis of antisocial personality disorder. The client had been arrested for stealing a car and then pushing it over a cliff. Which of the following behaviors should the nurse expect the client to display?

A. Little responsibility or concern for his current situation.
B. Anger and rage with the police and court for hospitalizing him against his will.
C. Withdrawal from others because of shame over his recent actions.
D. Remorse for stealing and destroying the car.

A. Little responsibility or concern for his current situation.

A pt has been admitted to the ED following a rape. The RN expects the pt may manifest symptoms of PTSD. The RN should be aware that this syndrome can best be described as which of the following?

A. Displacing feelings of anger onto hospital staff.
B. Guilt, shame, and the feeling that she provoked or should have prevented the rape.
C. Re-experiencing the fear and hopelessness of the original trauma.
D. Unconsciously denying the rape and rapidly returning the normal activities.

C. Re-experiencing the fear and hopelessness of the original trauma.

A client is counseling for generalized anxiety disorder and is prescribed buspirone (BuSpar) to control extreme restlessness and irritability. During client teaching about the medication, the nurse should inform the client that the most common side effect of BuSpar is:

A. Confusion
B. Arrythmias
C. Drowsiness
D. Ataxia

C. Drowsiness

An RN is caring for a pt admitting for ETOH detox. Which of the following meds is commonly used to manage ETOH withdrawal?

A. Barbiturates
B. Antianxiety agents
C. Antipsychotic drugs
D. Anticonvulsants

B. Antianxiety agents

A nurse is caring for a client with Wernicke Korsakoff syndrome. Which of the following should the nurse expect the client to exhibit?

A. Mood swings and suicidal ideation
B. Aggression and impulsiveness
C. Short-term memory loss and disorientation.
D. Suspicion and fearfulness

C. Short-term memory loss and disorientation.

A pt tells the RN that the TV is really a 2-way radio that states that, “Voices are coming from the TV, and everything we say in this room is being recorded.” Which of the following is an appropriate nursing response?

A. “What are the voices saying?”
B. “Do you recognize the voices?”
C. “That must be very frightening.”
D. “Is the TV turned on?”

C. “That must be very frightening.”

An RN is caring for a hospitalized pt who is experiencing an acute manic episode. Which of the following is the priority nursing intervention?

A. Maintain the pt’s contact with family.
B. Discourage pt’s use of vulgar language.
C. Protect the pt from impulsive behavior.
D. Redirect excessive energy to creative tasks.

C. Protect the pt from impulsive behavior.

An RN is providing teaching to a pt who is taking disulfiram (Antabuse) for the management of ETOH dependence. Which of the following should the RN encourage the pt to avoid?

A. Peppermint candy
B. Vanilla extract
C. Salt
D. Chocolate

B. Vanilla extract

The RN is providing family teaching about the med donepezil (Aricept) in the Tx for Alzheimer’s disease. Which of the following is an accurate statement about Aricept?

A. “Aricept prolongs the time and functioning of the earlier stages of the disease.”
B. “This med halts the disease process if it’s started upon the first recognition of dementia.”
C. “Aricept prevents memory loss evident in the last phase of the disease.”
D. “This med works most effectively when administered slowly with increasing daily dosages.”

A. “Aricept prolongs the time and functioning of the earlier stages of the disease.”

A depressed pt tells the RN, “I am too tired and depressed to attend group therapy today.” How should the RN respond?

A. “Attending group therapy, even if you’re tired, may help your depression.”
B. “That’s okay for today, but you will have to go tomorrow.”
C. “I will tell your provider how depressed you are.”
D. “If you do not go to therapy, I will have to chart that you refused.”

A. “Attending group therapy, even if you’re tired, may help your depression.”

An RN should know that an appropriate short-term goal for a pt exhibiting manic behavior is which of the following?

A. Chairing the unit’s self-government group
B. Identifying 3 strengths
C. Competing in a unit volleyball game
D. Painting alone for 15 mins

D. Painting alone for 15 mins

An RN has an order to administer donepezil (Aricept) daily to a pt with early Alzheimer’s disease. The RN should understand that this drug should be administered:

A. With 8oz of water
B. With dinner
C. Before breakfast
D. At bedtime

D. At bedtime

Which of the following should an RN expect to observe in a pt exhibiting impulsive behavior?

A. Good problem-solving skills
B. Commitment to long-term goals
C. Ability to delay gratification
D. Low tolerance for frustration

D. Low tolerance for frustration

A provider admits a pt to an ED program. The admitting RN learns that the pt has lost 25 lbs over the past month and now weighs 85 lbs. When assessing the pt, the RN should observe for which of the following as an early manifestation of anorexia nervosa?

A. Appetite loss
B. Tachycardia
C. Insomnia
D. Amenorrhea

D. Amenorrhea

Initially, an RN should expect a pt to react to a diagnosis of CA with:

A. Acceptance
B. Fear
C. Denial
D. Anger

C. Denial

A pt is transferred to a psych unit from the ED, where she was treated for self-inflicted injuries. Which of the following is the highest priority when planning care for the pt?

A. Promoting and maintaining pt safety.
B. Exploring the reasons for the pt’s behavior
C. Assisting the pt to recognize feelings
D. Providing strategies for alternative coping

A. Promoting and maintaining pt safety.

The RN is admitting a pt to the outpatient department for a second series of ECT treatments. The RN should give immediate consideration to which of the following statements by the pt?

A. “I just found out I am 3 months pregnant.”
B. “I only ate a light breakfast this morning.”
C. “I am having memory problems since the last treatment.”
D. “My partner will be back later to drive me home.”

B. “I only ate a light breakfast this morning.”

An RN is caring for an elderly pt in an inpatient mental health facility. The RN should understand which of the following with regard to this pt’s antidepressant med?

A. Elderly pts require lower doses of antidepressants than younger pts
B. Elderly pts cannot be safely treated with tricyclic antidepressants
C. Elderly pts respond more quickly to the therapeutic effects of antidepressants than younger pts
D. Elderly pts can be treated safely and effectively with all antidepressants

A. Elderly pts require lower doses of antidepressants than younger pts

An RN in an outpatient mental health clinic is caring for a pt diagnosed with antisocial personality disorder. Which of the following is the most appropriate nursing intervention for the pt?

A. Set limits on the inappropriate behavior
B. Ignore the inappropriate behavior
C. Isolate the pt during activity periods
D. Provide diversion for inappropriate behavior

A. Set limits on the inappropriate behavior

An RN is caring for a pt with agoraphobia. Which of the following techniques should the RN recognize as the most effective technique for treatment of agoraphobia?

A. Repeated exposure to situations that the pt fears
B. Distraction each time the pt brings up the problem
C. Teaching relaxation techniques
D. Gradual desensitization by controlled exposure to the situation the pt fears

D. Gradual desensitization by controlled exposure to the situation the pt fears

A pt is admitted with a Hx of extremely elevated, irritable mood for a week. On assessment, the RN notes grandiosity, insomnia, flight of ideas, and psychomotor agitation. Which of the following is the priority short term goal for the pt?

A. Stability of mood
B. Understanding of med regimen
C. Improvement in judgment
D. Adequate nutrition and rest patterns

D. Adequate nutrition and rest patterns

An RN is caring for a pt who has been takin lithium (Lithane) for the past 6 months. The pt’s provider determines that the pt is no longer responding well to the med. After DCing the lithium, the provider prescribes valproic acid (Depakote). What instructions should the RN give the pt regarding this med?

A. WBCs must be monitored regularly
B. A pretreatment EEG must be performed and repeated in 6 months.
C. Thyroid function tests must be performed every 6 months.
D. Liver function and hematology levels must be monitored regularly.

D. Liver function and hematology levels must be monitored regularly.

After a depressed pt is DC’d, the pt’s spouse stops attending family counseling sessions. The spouse tells the RN, “I don’t have time for all that talking.” Which of the following is a therapeutic response by the RN?

A. “It must be difficult for you to talk about these family problems.”
B. “You should continue attending the counseling sessions until the therapist tells you to stop.”
C. “Because your spouse’s condition is improving, you will be less involved in family therapy.”
D. “Continuing counseling is necessary if your spouse is to continue making progress.”

A. “It must be difficult for you to talk about these family problems.”

An RN is caring for a pt who has been diagnosed with antisocial personality disorder. Which of the following pt behaviors should indicate to the RN that he is making progress with treatment? (Select all that apply)

A. Assisting a roommate who is depressed to fill out a menu
B. Volunteering to chair the pt government meeting
C. Requesting a weekend pass to go home
D. Serving as the judge for a unit talent show
E. Leading a weekly community group

A. Assisting a roommate who is depressed to fill out a menu

C. Requesting a weekend pass to go home

An RN in an acute care mental health facility is caring for a pt newly diagnosed with antisocial personality disorder. Which of the following actions should the RN plan to include in the pt care?

A. Supervising the pt to prevent any destructive behavior
B. Ignoring the pt’s past acts and focusing on current issues
C. Setting clear rules and expectations for the pt’s behavior
D. Help the pt to gain insight into what motivates the behavior

C. Setting clear rules and expectations for the pt’s behavior

A pt who was admitted yesterday for alcoholism tells the RN, “I have not had anything to drink for 24 hours.” The pt reports feeling anxious and shaky. Based on knowledge of ETOH withdrawal, what other behaviors should the RN expect to pt to display during the early phase of ETOH withdrawal?

A. Confusion, visual hallucinations, delusions
B. Coarse tremors, tachycardia, insomnia
C. Disorientation, confabulation, memory deficits
D. Incoordination, impaired thinking, irregular eye movements.

B. Coarse tremors, tachycardia, insomnia

An RN is caring for a hospitalized pt. The pt is exhibiting antisocial behavior. Which of the following is a therapeutic treatment approach?

A. Negotiating the treatment plan with the pt.
B. a one-to-one RN-pt relationship
C. Participation in group therapy
D. Providing an unstructured environment

C. Participation in group therapy

Several teenagers bring an unconscious friend to the ED and tell the RN that the pt, “Uses drugs, but we don’t know what this time.” When assessing the pt’s eyes, the RN should suspect a cocaine OD when she observes which of the following?

A. Pinpoint pupils
B. Dilated pupils
C. Bloodshot sclera
D. Rapid movement

B. Dilated pupils

An unconscious pt is brought to the ED due to heroin OD. After regaining consciousness, the pt is transferred to the substance abuse treatment unit. Which of the following findings should the RN identify as a manifestation of opioid withdrawal?

A. Euphoria
B. Rhinorrhea
C. Slurred speech
D. Head nodding

B. Rhinorrhea

An RN is caring for a pt who is diagnosed with antisocial personality disorder. The RN should understand that which of the following manifestations is inconsistent with this diagnosis?

A. Poor frustration tolerance
B. Intense guilt
C. Grandiosity
D. Fighting

B. Intense guilt

An RN should expect a prescription for which of the following to manage a pt’s withdrawal from ETOH?

A. Haloperidol (Haldol)
B. Disulfiram (Antabuse)
C. Chlordiazepoxide (Librium)
D. Promethazine (Phenergan)

C. Chlordiazepoxide (Librium)

An RN is required to report any suspected child abuse. Which of the following is the most important observation that an RN can use as justification for reporting suspected abuse?

A. There is inconsistency between the Hx and the injury
B. A child presents with visible bruises
C. A caregiver, rather than a parent, brings the child to the clinic.
D. A child is crying inconsolably while being held by a parent.

A. There is inconsistency between the Hx and the injury

The nursing staff decides to develop a behavioral modification program to help a young anorexic pt gain WT. Which of the following interventions is contraindication for the pt?

A. Allowing the pt to select meals from the same menu offered to all pts
B. Providing positive reinforcement for each pound the pt gains?
C. Permitting the pt to spend some quiet time alone after each meal
D. Refraining from commenting about the pt’s eating during meal times.

C. Permitting the pt to spend some quiet time alone after each meal

An older adult pt is admitted to the hospital for diagnostic confirmation and management of probable delirium. Which of the following statements by the pt’s son would best support the Dx of delirium?

A. “The change in behavior came on so quickly! I wasn’t sure what was happening to her.”
B. “This is so unlike my mother to behave like this. Maybe, the behavior is age-related.”
C. “She just didn’t seem to know what she was doing. She would forget what she had for breakfast.”
D. “My mother has always been so independent. She’s lived alone since my father died years ago.”

A. “The change in behavior came on so quickly! I wasn’t sure what was happening to her.”

During the assessment of a newly admitted pt, an RN learns of the pt’s long-term use and dependence on lorazepam (Ativan). Which of the following nursing actions is appropriate for this pt?

A. Taper the med gradually.
B. Provide a high-calorie dietary replacement.
C. Monitor serum blood levels.
D. Implement restraints and seclusion PRN

A. Taper the med gradually.

An RN is caring for a pt who is prescribed methadone (Dolophine). The RN should recognize that methadone maintenance can be effective drug replacement for individuals addicted to which of the following?

A. Amphetamines
B. Opiates
C. Barbiturates
D. Hallucinogenics

B. Opiates

An RN should recognize that which of the following meds may safely be prescribed for a pt already taking lithium (Lithane)?

A. ibuprofen (Advil)
B. succinylcholine (Anectine)
C. valproic acid (Depakene)
D. HCTZ (HydroDIURIL)

C. valproic acid (Depakene)

An RN is caring for a pt who is in early stages of Alzheimer’s disease. The RN should understand that the pt is capable of performing which of the following tasks?

A. Remembering a daily schedule
B. Solving a simple math problem
C. Coping with stressful experiences
D. Recalling events of the distant past

D. Recalling events of the distant past

A pt on the psych unit is unresponsive or mumbles incoherently whenever the RN asks the pt questions. Which of the following actions will facilitate communication?

A. Filling silent periods by talking about topics interesting to the RN
B. Sitting quietly with the pt until the pt indicates a willingness to talk
C. Encouraging the pt to talk by asking direct questions
D. Continuing to speak with the pt using short, clear statements, or open-ended questions

D. Continuing to speak with the pt using short, clear statements, or open-ended questions

An RN is interviewing an elderly pt who may have been abused by her neighbor, who provides much of the pt’s care. The RN’s interview questions should:

A. Avoid directly asking if the pt has ever been hurt by someone.
B. Be confrontational
C. Be non-threatening and non-judgmental
D. Avoid asking the pt about the potential abuse

C. Be non-threatening and non-judgmental

An RN is administering a benzo antianxiety med. Which of the following is the most common side effect of benzos?

A. Flatulence
B. HA
C. Confusion
D. Sedation

D. Sedation

A home care RN is speaking to a church group on the Dx and Tx of Alzheimer’s disease. The RN should conclude that a member of the group requires further teaching when she states that Alzheimer’s disease is characterized by which of the following?

A. Disorientation and impaired judgment
B. Acute confusion and inattention
C. Personality change and apathy
D. Anxiety and memory loss

B. Acute confusion and inattention

An unconscious pt is brought to the ED by 2 friends who report the pt took an OD of heroin. The narcotic antagonist, nalaxone (Narcan), is administered. After administering the med, the RN should monitor the pt closely for which of the following?

A. Seizure activity
B. Resp. depression
C. N
D. Kidney failure

B. Resp. depression

An RN on the surgical unit is providing post-op care to an older adult pt. The pt has begun having periods of agitation at night that include screaming out loudly for help. Which of the following nursing interventions should be avoided?

A. Request an order for a sedative med
B. Remain calm, and encourage the pt to verbally express fears.
C. Keep a nightlight on in the pt’s room
D. Assess the pt’s level of px or the presence of other physical discomfort

A. Request an order for a sedative med

An RN should understand that the best justification for involuntary admission of a pt for psych Tx is which of the following?

A. The pt is unable to manage the affairs necessary for daily life.
B. The pt has broken the law
C. A psychiatrist has determined that the pt’s behavior is irrational
D. The pt exhibits behavior that is a threat to either himself or society

D. The pt exhibits behavior that is a threat to either himself or society

An RN is caring for a pt who was admitted recently with a Dx of schizophrenia, paranoid type. Since admission, the pt has had several verbal outbursts of anger but has not been violent. The RN notices that the pt is pacing up and down the hall very rapidly and muttering in an angry manner. Which of the following should the RN do first?

A. Gather several staff members and approach the pt together.
B. Prepare a PRN does of IM haloperidal (Haldol) for the pt
C. Observe the pt’s behavior, and approach him in a non-threatening manner
D. Contact the pt’s provider to request an order to place the pt in seclusion.

C. Observe the pt’s behavior, and approach him in a non-threatening manner

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