NURS 410 psych test 3 (Ch. 12, 15-17, & 23) PQ's

A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably:
a. readily seek psychiatric counseling.
b. be resistant to accepting psychiatric help.
c. attend psychotherapy sessions without encouragement.
d. be eager to discover the true reasons for physical symptoms.
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A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably:
a. readily seek psychiatric counseling.
b. be resistant to accepting psychiatric help.
c. attend psychotherapy sessions without encouragement.
d. be eager to discover the true reasons for physical symptoms.
b. be resistant to accepting psychiatric help.
A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurses planning for this patient? The patient is:
a. suppressing accurate feelings regarding the problem.
b. relieving anxiety through the physical symptom.
c. meeting needs through hospitalization.
d. refusing to disclose genuine fears.
b. relieving anxiety through the physical symptom.
A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should:
a. establish a buddy system with other patients who can feed the patient at each meal.
b. expect the patient to feed himself or herself after explaining the arrangement of the food on the tray.
c. direct the patient to locate items on the tray independently and feed himself or herself unassisted.
d. address the needs of other patients in the dining room, and then feed this patient.
b. expect the patient to feed himself or herself after explaining the arrangement of the food on the tray.
A patient with blindness related to a functional neurological (conversion) disorder says, All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital dont find me interesting. Which nursing diagnosis is most relevant?
a. Social isolation
b. Chronic low self-esteem
c. Interrupted family processes
d. Ineffective health maintenance
b. Chronic low self-esteem
To assist a patient diagnosed with a somatic system disorder, a nursing intervention of high priority is to:
a. imply that somatic symptoms are not real.
b. help the patient suppress feelings of anger.
c. shift the focus from somatic symptoms to feelings.
d. investigate each physical symptom as soon as it is reported.
c. shift the focus from somatic symptoms to feelings.
A patient who fears serious heart disease was referred to the mental health center by a cardiologist after diagnostic evaluation showed no physical illness. The patient says, My heart misses beats. Im frequently absent from work. I dont go out much because I need to rest. Which health problem is most likely?
a. Body dysmorphic disorder
b. Antisocial personality disorder
c. Illness anxiety disorder (hypochondriasis)
d. Persistent depressive disorder (dysthymia)
c. Illness anxiety disorder (hypochondriasis)
A nurse assessing a patient diagnosed with a somatic system disorder is most likely to note that the patient:
a. readily sees a relationship between symptoms and interpersonal conflicts.
b. rarely derives personal benefit from the symptoms.
c. has little difficulty communicating emotional needs.
d. has unmet needs related to comfort and activity.
d. has unmet needs related to comfort and activity.
To plan effective care for patients diagnosed with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms:
a. are generally chronic in nature.
b. have a physiological basis.
c. can be voluntarily controlled.
d. provide relief from health anxiety.
d. provide relief from health anxiety.
A patient diagnosed with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patients disabling symptoms as evidenced by the spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will:
a. assume roles and functions of the other family members.
b. demonstrate a resumption of former roles and tasks.
c. focus energy on problems occurring in the family.
d. rely on family members to meet his or her personal needs.
b. demonstrate a resumption of former roles and tasks.
A woman wears a size 7 shoe. She says, My feet are huge. Ive asked three orthopedists to surgically reduce my feet. The patient tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
a. Dissociative amnesia with fugue
b. Illness anxiety disorder
c. Body dysmorphic disorder
d. Dissociative identity disorder
c. Body dysmorphic disorder
Which assessment finding best supports the diagnosis of dissociative amnesia with fugue? The patient states: a. I cannot recall why Im living in this town. b. I feel as if Im living in a fuzzy dream state. c. I feel like different parts of my body are at war. d. I feel very anxious and worried about my problems.a. I cannot recall why Im living in this town.A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later, and then sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? a. Functional neurological (conversion) disorder b. Dissociative identity disorder c. Dissociative amnesia d. Body dysmorphic disorderb. Dissociative identity disorderA nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? a. Since my father died, Ive been short of breath and had sharp pains that go down my left arm, but I think its just indigestion. b. I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think Im getting seriously dehydrated. c. Sexual intercourse is painful. I pretend as if Im asleep so I can avoid it. I think its starting to cause problems with my marriage. d. I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus.a. Since my father died, Ive been short of breath and had sharp pains that go down my left arm, but I think its just indigestion.A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? a. Anxiety b. Risk for suicide c. Disturbed body image d. Ineffective role performanceb. Risk for suicideSelect the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder: Disturbed personal identity, related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.d. cognitive distortions associated with unresolved childhood abuse issues.For a patient diagnosed with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: a. functioning independently. b. verbalizing feelings of safety. c. regularly attending diversional activities. d. describing previously forgotten experiences.b. verbalizing feelings of safety.A person comes to the clinic reporting, I wear a scarf across my lower face when I go out but because of my ugly appearance. Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? a. Dissociative identity disorder b. Body dysmorphic disorder c. Pseudocyesis d. Malingeringb. Body dysmorphic disorderA nurse counseling a patient diagnosed with dissociative identity disorder (DID) should understand that the assessment of highest priority is: a. risk for self-harm b. cognitive functioning c. identification of drug abuse d. readiness to reestablish identity or memorya. risk for self-harmA patient says, I feel detached and weird all the time, like Im looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint? a. Depersonalization b. Hypochondriasis c. Dissociation d. Malingeringa. DepersonalizationA patient reports fears of having cervical cancer and says to the nurse, Ive had Pap smears by six different doctors. The results are normal, but Im sure thats because of errors in the laboratory. Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Illness anxiety disorder (hypochondriasis) c. Body dysmorphic disorder d. Dissociative amnesia with fugueb. Illness anxiety disorder (hypochondriasis)A patient diagnosed with somatic symptom disorder says, I have pain from an undiagnosed injury. I cant take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much. It is important for the nurse to assess: a. mood. b. cognitive style. c. secondary gains. d. identity and memory.c. secondary gains.The causes of somatic system disorders may be related to: a. faulty perceptions of body sensations. b. traumatic childhood events. c. culture-bound phenomena. d. mood instability.a. faulty perceptions of body sensations.What is the primary difference between somatic system disorders and dissociative disorders? a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic. b. Dissociative disorders are precipitated by psychological factors, whereas somatic system disorders are related to stress. c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound. d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychological stress through somatic symptoms.d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychological stress through somatic symptoms.A patient says, I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day. Which response by the nurse fosters cognitive restructuring? a. You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking. b. Lets see whether any other explanations for your vomiting are possible. c. You seem so worried. Lets talk about how youre feeling. d. We should talk about something else.b. Lets see whether any other explanations for your vomiting are possible.Which treatment modality should a nurse recommend to help a patient diagnosed with somatic symptom disorder cope more effectively? a. Flooding b. Relaxation c. Response prevention d. Systematic desensitizationb. RelaxationA patient diagnosed with depersonalization disorder tells the nurse, Its starting again. I feel as though Im going to float away. The nurse should help the patient by: a. encouraging meditation. b. administering an anxiolytic medication. c. helping the patient visualize a pleasant scene. d. helping the patient focus on the here and now.d. helping the patient focus on the here and now.A patient diagnosed with somatic symptom disorder has been in treatment for 4 weeks. The patient says, Although Im still having pain, I notice it less and am able to perform more activities. The nurse should evaluate the treatment plan as: a. unsuccessful. b. minimally successful. c. partially successful. d. totally achieved.c. partially successful.A patient diagnosed with somatic symptom disorder says, Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear. Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performancea. Spiritual distress e. Ineffective role performanceA nurse assesses a patient suspected to have somatic system disorder. Which findings support the diagnosis? Select all that apply. a. Female b. Reports frequent syncope c. Complains of heavy menstrual bleeding d. First diagnosed with psoriasis at 12 years of age e. Reports of back pain, painful urination, frequent diarrhea, and hemorrhoidsa. Female b. Reports frequent syncope c. Complains of heavy menstrual bleeding e. Reports of back pain, painful urination, frequent diarrhea, and hemorrhoidsA patients roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. Dissociative identity disorder (DID) is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply. a. Are you sexually promiscuous? b. Do you think you need an antidepressant medication? c. Have you ever found yourself someplace and did not know how you got there? d. Are your memories of childhood clear and complete, or do you have blank spots? e. Have you ever found new things in your belongings that you cant remember buying?c. Have you ever found yourself someplace and did not know how you got there? d. Are your memories of childhood clear and complete, or do you have blank spots? e. Have you ever found new things in your belongings that you cant remember buying?A client is diagnosed with dysthymic disorder. Which 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 lifeD. Gloomy and pessimistic outlook on lifeA 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 anorexiaB. Social isolation R/T poor self-esteem AEB secluding self in roomA 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. The client has maxed-out charge cards and exhibits promiscuous behaviors.A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 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/dLA. Thyroid-stimulating hormone (TSH) level of 6.2 U/mLA depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. 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. According to learning theory, depression is a result of repeated failures.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. Depression can generate somatic symptoms that can mask actual physical disorders.A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. 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. Fluoxetine (Prozac)A nurse admits an older client who is experiencing 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 disorderC. To rule out senile dementiaA confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different seratonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIsD. Serotonin syndrome caused by ingestion of two different SSRIsA 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 reply? 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. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis."A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) 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 colaA. Pepperoni pizza and red wineA client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."B. "It is going to take 2 to 3 weeks in order for me to begin to feel better."A client is admitted to the psychiatric unit with a diagnosis of major depression. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolationA. A simple, structured daily schedule with limited choices of activitiesAn isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."B. "I'll walk with you to the day room. Group is about to start."Sertraline (Zoloft) has been prescribed for a client complaining of poor appetite, fatigue, and anhedonia. Which consideration should the nurse recognize as influencing this prescriptive choice? A. Zoloft is less expensive for the client. B. Zoloft is extremely sedating and will help with sleep disturbances. C. Zoloft has less adverse side effects than other antidepressants. D. Zoloft begins to improve depressive symptoms quickly.C. Zoloft has less adverse side effects than other antidepressants.What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular blood work B. The client's mood and affect score, using the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatmentC. The client's cognitive ability to understand information about the medicationA client diagnosed with seasonal affective disorder (SAD) states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's symptoms. A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you experienced any traumatic events that triggered this mood change?" C. "People who have seasonal mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"D. "Help me understand what you mean when you say, 'feeling down'?"A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."B. "Because we are concerned about your safety, we will continue to observe you."A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effective of suicide on family dynamics. B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self esteem.B. Carefully and unobtrusively observe based on assessed data, at varied intervals around the clock.The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to assess and attempt to modify the negative thought patterns of these clients. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theoryC. Cognitive theoryWhich client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "I deserve to feel this way."D. "I deserve to feel this way."A 75-year-old client diagnosed with a long history of depression is currently on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell countC. Risk for injury R/T orthostatic hypotensionA client is admitted with a diagnosis of depression NOS (not otherwise specified). Which client statement would describe a somatic symptom that can occur with this diagnosis? A. "I am extremely sad, but I don't know why." B. "Sometimes I just don't want to eat because I ache all over." C. "I feel like I can't ever make the right decision." D. "I can't seem to leave the house without someone with me."B. "Sometimes I just don't want to eat because I ache all over."A client diagnosed with major depressive disorder was raised in an excessively religiously based household. Which nursing intervention would be most appropriate to address this client's underlying problem? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.A. Encourage the client to bring into awareness underlying sources of guilt.A nurse is caring for four clients taking various medications including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. ParnateD. ParnateA client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Expressions of poor self-esteemB. Lack of attention to grooming and hygieneA newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "I'm glad you shared this. There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."B. "Bringing this up is a very positive action on your part."A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.) A. Sad mood on most days B. Mood rating of 2/10 for the past 6 months C. Labile mood D. Sad mood for the past 3 years after spouse's death E. Pressured speech when communicatingA. Sad mood on most days D. Sad mood for the past 3 years after spouse's deathAn individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.) A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressorsB. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioningA client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.) A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." E. "I'll be sure not to stop this medication abruptly."A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad moodc. Poor judgment and hyperactivityA patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, Ill punch you, munch you, crunch you, while twirling and shadowboxing. Then the patient says gaily, Do you like my scarves? Herethey are my gift to you. How should the nurse document the patients mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confidenta. Labile and euphoricA patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen managementa. Risk for injuryA patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. Stop that! No one did anything to provoke an attack by you. b. If you do that one more time, you will be secluded immediately. c. Do not hit anyone. If you are unable to control yourself, we will help you. d. You know we will not let you hit anyone. Why do you continue this behavior?c. Do not hit anyone. If you are unable to control yourself, we will help you.This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.b. drink six servings of a high-calorie, high-protein drink each day.A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.b. bring hyperactivity under rapid control.A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)c. carbamazepine (Tegretol)The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.a. several factors, including genetics, are implicated.The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurses best response. a. A high proportion of patients diagnosed with bipolar disorders are found among creative writers. b. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder. c. Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses. d. More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds.b. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder.A patient diagnosed with bipolar disorder commands other patients, Get me a book. Take this stuff out of here, and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse. a. Distraction: Lets go to the dining room for a snack. b. Humor: How much are you paying servants these days? c. Limit setting: You must stop ordering other patients around. d. Honest feedback: Your controlling behavior is annoying others.a. Distraction: Lets go to the dining room for a snack.A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testinga. within therapeutic limitsConsider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)c. lamotrigine (Lamictal)When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on the patients behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.b. Set limits on the patients behavior as necessary.At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. Extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholsteryb. Neutral walls with pale, simple accessoriesA patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.b. Hold a staff meeting to discuss consistency and limit-setting approaches.A patient experiencing acute mania undresses in the group room and dances. The nurses first intervention would be to: a. quietly ask the patient, Why dont you put on your clothes? b. firmly tell the patient, Stop dancing, and put on your clothing. c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.c. put a blanket around the patient, and walk with the patient to a quiet room.A patient experiencing acute mania waves a newspaper and says, I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes. Select the nurses most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.b. Invite the patient to sit with the nurse and look at new fashion magazines.A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.a. meals.A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.a. maintain normal salt and fluids in the diet.Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive copingb. Disturbed sleep patternWhich dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped creamc. Broiled chicken breast on a roll, an ear of corn, appleOutcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. maintaining an interest in the environment. b. developing an optimistic outlook. c. self-control of distorted thinking. d. stabilizing the sleep pattern.c. self-control of distorted thinking.Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. Converses without interrupting; clothing matches; participates in activities. b. Irritable, suggestible, distractible; napped for 10 minutes in afternoon. c. Attention span short; writing copious notes; intrudes in conversations. d. Heavy makeup; seductive toward staff; pressured speech.a. Converses without interrupting; clothing matches; participates in activities.A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?a. Monitor physiologic functioning b. Provide a subdued environment c. Supervise personal hygiene d. Observe for mood changesb. Provide a subdued environmentA patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurses best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patients speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.d. Consider the need to check the lithium level. The patient may not be swallowing medications.A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.d. arrange for one-on-one supervision.A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, Ill throw the pool balls if anyone comes near me. The nurses first intervention is to: a. tell the patient, You need to be secluded. b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.c. clear the room of all other patients.A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edemac. Diaphoresis, weakness, and nauseaAfter hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patients family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducationd. PsychoeducationA patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, Do I have to keep taking this lithium even though my mood is stable now? Select the nurses most appropriate response. a. You will be able to stop the medication in approximately 1 month. b. Taking the medication every day helps prevent relapses and recurrences. c. Usually patients take this medication for approximately 6 months after discharge. d. Its unusual that the health care provider has not already stopped your medication.b. Taking the medication every day helps prevent relapses and recurrences.A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, Ive had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do? The nurse should advise the patient: a. Restrict oral fluids for 24 hours and stay in bed. b. Have someone bring you to the clinic immediately. c. Drink a large glass of water with 1 teaspoon of salt added. d. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.b. Have someone bring you to the clinic immediately.Lithium is prescribed for a new patient. Which information from the patients history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failured. Congestive heart failureA patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply. a. Provide structure b. Limit credit card access c. Encourage group social interaction d. Limit work to half days e. Monitor the patients sleep patternsa. Provide structure b. Limit credit card access e. Monitor the patients sleep patternsA nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolationb. Disturbed thought processes c. Sleep deprivationA patient tells the nurse, I am so ashamed of being bipolar. When Im manic, my behavior embarrasses my family. Even if I take my medication, theres no guarantee I wont have a relapse. I am such a burden to my family. These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behaviora. Powerlessness c. Chronic low self-esteemA person diagnosed with schizophrenia has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, Theyre all plotting to destroy me. Select the nurses most therapeutic response. a. Everyone here is trying to help you. No one wants to harm you. b. Feeling that people want to destroy you must be very frightening. c. That is not true. People here are trying to help if you will let them. d. Staff members are health care professionals who are qualified to help you.b. Feeling that people want to destroy you must be very frightening.A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, I saw two doctors talking in the hall. They were plotting to kill me. The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.b. an idea of reference.A patient diagnosed with schizophrenia says, My co-workers are out to get me. I also saw two doctors plotting to overdose me. How does this patient perceive the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarrec. DangerousWhen a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, I stopped taking those pills. They made me feel like a robot. What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nosea. Sedation and muscle stiffnessA nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, I dont like taking pills. Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Inpatient hospitalization because of the high risk for exacerbation of symptomsa. Use of a long-acting antipsychotic injectionsA patients care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open placesb. Darting eyes, tilted head, mumbling to selfA health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)d. aripiprazole (Abilify)A patient diagnosed with schizophrenia tells the nurse, I eat skiller. Tend to end. Easter. It blows away. Get it? Select the nurses best response. a. Nothing you are saying is clear. b. Your thoughts are very disconnected. c. Try to organize your thoughts, and then tell me again. d. I am having difficulty understanding what you are saying.d. I am having difficulty understanding what you are saying.A patient diagnosed with schizophrenia has catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and securityb. PhysiologicA patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patients activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. voluntarily accept tube feeding by day 2.b. perform self-care activities with coaching by the end of day 3.A nurse observes a patient who is diagnosed with schizophrenia. The patient is standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawalb. Waxy flexibilityWhich patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribedd. 40 years old; frequent relapses since age 18; often does not take medication as prescribedA patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines b. Allow the patient to telephone a local restaurant to deliver meals c. Offer to taste each portion on the tray for the patient d. Begin tube feedings or total parenteral nutritiona. Allow the patient to have supervised access to food vending machinesA community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurses best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patients arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurses identity; encourage the patient to talk while the nurse works on reports.a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.Patients diagnosed with schizophrenia who are suspicious and withdrawn: a. universally fear sexual involvement with therapists. b. are socially disabled by the positive symptoms of schizophrenia. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.d. avoid relationships because they become anxious with emotional closeness.A newly admitted patient diagnosed with schizophrenia says, The voices are bothering me. They yell and tell me Im bad. I have got to get away from them. Select the nurses most helpful reply. a. Do you hear the voices often? b. Do you have a plan for getting away from the voices? c. I will stay with you. Focus on what we are talking about, not the voices. d. Forget the voices. Ask some other patients to sit and talk with you.c. I will stay with you. Focus on what we are talking about, not the voices.A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisiac. PseudoparkinsonismA patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patients head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisiaa. Acute dystonic reactionAn acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patients head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.A patient has taken trifluoperazine (Stelazine) 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patients neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effectsb. Tardive dyskinesiaA nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurses best response. a. Why are you laughing? b. Please share the joke with me. c. I dont think I said anything funny. d. You are laughing. Tell me whats happening.d. You are laughing. Tell me whats happening.Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behaviorb. Social withdrawal and ineffective communicationWhat assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologismsa. Withdrawal, misinterpreting, poor concentration, and preoccupation with religionA patient diagnosed with schizophrenia says, Everyone has skin lice that jump on you and contaminate your blood. Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoiad. ParanoiaA patient diagnosed with schizophrenia has paranoid thinking. The patient angrily tells a nurse, You are mean and nasty. No one trusts you or wants to be around you. Select the most likely analysis. The patient: a. is trying to manipulate the nurse by using negative comments. b. is likely to experience disorganization and catatonia in the near future. c. is jealous of the nurses position of power in the relationship. d. may be identifying another persons shortcomings in order to preserve his or her own self-esteem.d. may be identifying another persons shortcomings in order to preserve his or her own self-esteem.A patient diagnosed with schizophrenia says, High heat. Last time here. Did you get a coat? What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative loosenessd. Associative loosenessA patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. chlorpromazine (Thorazine) d. diphenhydramine (Benadryl)b. olanzapine (Zyprexa)The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and the familys role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Familya. PsychoeducationalA patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, Demons are in the basement and they can come through the floor. The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapsed. relapseA patient diagnosed with schizophrenia begins to talks about cracklomers in the local shopping mall. The term cracklomers should be documented as: a. neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.a. neologism.A patient diagnosed with schizophrenia anxiously says, I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror. While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patients shoulders. c. place a hand on the patients arm and exert light pressure. d. maintain a normal social interaction distance from the patient.d. maintain a normal social interaction distance from the patient.A patient diagnosed with schizophrenia has auditory hallucinations. The patient anxiously tells the nurse, The voice is telling me to do things. Select the nurses priority assessment question. a. How long has the voice been directing your behavior? b. Do the messages from the voice frighten you? c. Do you recognize the voice speaking to you? d. What is the voice telling you to do?d. What is the voice telling you to do?A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 102.8 F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurses best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, low fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.d. Neuroleptic malignant syndrome. Immediately notify the health care provider.A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5?26?3? tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measuresb. Weight management strategiesA patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitationc. Poor personal hygieneThe family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurses response should be based on which models? Select all that apply. a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stressa. Neurobiological d. GeneticA nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taking your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smokingb. The importance of correctly taking your medication e. Ways to quit smokingA patient diagnosed with schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, Two staff members I saw talking were plotting to assault me. Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolationa. Risk for other-directed violence b. Disturbed thought processesWhich changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiencyb. Serotonin deficiencyA college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in a dorm roomc. Giving away sweatersA nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.c. suicide potential.A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimenc. Risk for suicideA person attempts suicide by overdose, is treated in the emergency department, and then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, There must be a mistake. This could not have happened. Weve given our child everything. The parents reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.a. denial.An adolescent tells the school nurse, My friend threatened to take an overdose of pills. The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. Why do you want to kill yourself? b. Do you have access to medications? c. Have you been taking drugs and alcohol? d. Did something happen with your parents?b. Do you have access to medications?An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for five days. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.a. Supervise the patient 24 hours a day.A nurse and patient construct a no-suicide contract. Select the preferable wording for the contract. a. I will not try to harm myself during the next 24 hours. b. I will not make a suicide attempt while I am hospitalized. c. For the next 24 hours, I will not kill or harm myself in any way. d. I will not kill myself until I call my primary nurse or a member of the staff.c. For the next 24 hours, I will not kill or harm myself in any way.A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.c. establish a rapport with the patient.Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, I am considering suicide. a. Im glad you shared this. Please do not worry. We will handle it together. b. I think you should admit yourself to the hospital to get help. c. We need to talk about the good things you have to live for. d. Bringing this up is a very positive action on your part.d. Bringing this up is a very positive action on your part.Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Attending a self-help group for survivors c. Contracting for two sessions of group therapy d. Completing a psychological postmortem assessmentb. Attending a self-help group for survivorsWhich statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.a. As depression lifts, physical energy becomes available to carry out suicide.A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. I wish I were dead. b. Life is not worth living. c. I have a plan that will fix everything. d. My family will be better off without me.c. I have a plan that will fix everything.A depressed patient says, Nothing matters anymore. What is the most appropriate response by the nurse? a. Are you having thoughts of suicide? b. I am not sure I understand what you are trying to say. c. Try to stay hopeful. Things have a way of working out. d. Tell me more about what interested you before you began feeling depressed.a. Are you having thoughts of suicide?A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre taking control of your problems and trying to find solutions. c. When you have bad feelings, try to focus on positive experiences from your life. d. Lets consider which problems are most important and which are less important.d. Lets consider which problems are most important and which are less important.When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients social supportc. Availability of means and lethality of methodWhich understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.d. experiencing hopelessness.Which statement by a patient during an assessment interview should alert the nurse to the patients need for immediate, active intervention? a. I am mixed up, but I know I need help. b. I have no one for help or support. c. It is worse when you are a person of color. d. I tried to get attention before I shot myself.b. I have no one for help or support.The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.a. hopelessness.Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friendsa. Jumping from a 100-foot-high railroad bridge located in a deserted area late at nightWhich individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate glandd. A 79-year-old single white man with cancer of the prostate glandA nurse answers a suicide crisis line. A caller says, I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. Im going to shoot myself in the heart. How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High leveld. High levelA staff nurse tells another nurse, I evaluated a new patient using the SAD PERSONS scale and got a score of 10. Im wondering if I should send the patient home. Select the best reply by the second nurse. a. That action would seem appropriate. b. A score over 8 requires immediate hospitalization. c. I think you should strongly consider hospitalization for this patient. d. Give the patient a follow-up appointment. Hospitalization may be needed soon.b. A score over 8 requires immediate hospitalization.A patient recently hospitalized for two weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.b. Hold a staff meeting to express feelings and plan the care for other patients.A severely depressed patient who has been on suicide precautions tells the nurse, I am feeling a lot better, so you can stop watching me. I have taken too much of your time already. Which is the nurses best response? a. I wonder what this sudden change is all about. Please tell me more. b. I am glad you are feeling better. The team will consider your request. c. You should not try to direct your care. Leave that to the treatment team. d. Because we are concerned about your safety, we will continue with our plan.d. Because we are concerned about your safety, we will continue with our plan.A new nurse says to a peer, My newest patient is diagnosed with schizophrenia. At least I wont have to worry about suicide risk. Which response by the peer would be most helpful? a. Lets reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia. b. Suicide is a risk for any patient diagnosed with schizophrenia who uses alcohol or drugs. c. Patients diagnosed with schizophrenia are usually too disorganized to attempt suicide. d. Visual hallucinations often prompt suicide among patients diagnosed with schizophrenia.a. Lets reconsider your plan. Suicide risk is high in patients diagnosed with schizophrenia.The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which comment by the nurse is accurate? a. Genetics are associated with suicide risk. Monitoring and support are important. b. Apathy underlies suicide. Instilling motivation is the key to health maintenance. c. Your child is unlikely to act out suicide when identifying with a suicide victim. d. Fraternal twins are at higher risk for suicide than identical twins.a. Genetics are associated with suicide risk. Monitoring and support are important.A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliationc. Recent stressful life event d. Self-imposed isolation e. Shame or humiliationA patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patients plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patients possession. c. Maintain arms length, one-on-one nursing observation around the clock. d. Check the patients whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patients whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patients possession. c. Maintain arms length, one-on-one nursing observation around the clock.A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injurya. 82-year-old white man b. 17-year-old white female adolescent e. 22-year-old man with traumatic brain injuryA nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Oppositional defiant disorder e. Post-traumatic stress disorderc. Traumatic brain injury e. Post-traumatic stress disorder