Exam 1
Donald is inpatient in the psychiatric unit after being medically cleared from the hospital after an intentional overdose. What nursing problem takes priority?
Safety
Greg is pacing around the milieu. His pupils are dilated and he states he is expecting a call from Donald Trump. What diet considerations need to be made?
High protein, high calorie, finger foods
He is in mania
Selena is a 15 year old female who presented to the emergency department for fatigue. Upon reviewing her electrolytes she has low potassium and magnesium. She has a BMI of 22. Which eating disorder is most likely?
Bulimia Nervosa
2 year old Sabrina was admitted to the hospital for a broken arm. When doing a full head-to-toe assessment on her you notice various bruises in different locations. As a nurse you understand that this is your next step.
Notify child protective services.
You are educating a patient on side effects of clozapine. Name 3 side effects with at least one being possibly life threatening as well as the black box warning.
Life threatening: NMS, TdP, VF/VT, hypo/hypertension, leukopenia, agranulocytosis, SZ, GI obstruction, paralytic ileus, pulmonary emboli
sedation, agitation, dizziness, insomnia, constipation, N/V, abd discomfort, anorexia, dry mouth, dyspepsia, SOB
BBW: increased risk of death in dementia related psychosis
Jebediah is a 63 year old male who states, "I just want to die. Give me a gun." What type of inpatient stay should be expected?
Involuntary
A nursing student states she observed a patient as happy and attempted to gift her Beats headphones. You recognize this as:
A. A grim sign that the patient is about to commit suicide
B. The patient is ready for discharge
C. The patient's antidepressants are working
D. The patient is trying to become intimate with the student
A.
Sudden surge of happiness/energy, giving away valuables, stating life is worthless, and stating everything will be better soon are grim signs that a patient is about to commit suicide
A nurse is caring for a 45-year-old patient admitted to the medical unit for alcohol detoxification. The patient was admitted 18 hours ago with a blood alcohol level of 0.28%. The patient now reports feeling anxious and is visibly trembling. Vital signs are: BP 158/96 mmHg, HR 110 bpm, RR 22/min, Temp 99.8°F (37.7°C). Which nursing action is the priority?
A) Assist the patient with hygiene care to improve self-esteem
B) Offer the patient a high-protein snack and encourage fluid intake
C) Encourage the patient to discuss feelings of anxiety and explore harmful thoughts
D) Notify the healthcare provider immediately about the vital sign changes
D
He is showing signs of alcohol withdrawal which can cause DT and death.
You are educating a nursing student on sexual assault and nursing care. Which of the following indicates the student comprehends the material?
A).A majority of females that have been sexually assaulted are assaulted for the first time by the age of 25
B). Sexual assault is when a man unconsensually touches a woman
C). Clothing choice matters in relevance of sexual assault
D). The SANE nurse's job to interrogate even if the questions asked make the victim uncomfortable
A
79% of women who are sexually assaulted are first assaulted by 25
The definition of sexual assault varies by state and both males and females can be the victim/offender
Clothing choice does NOT have any significance, victim blaming is nontherapeutic
The role of a SANE is to collect evidence, not interrogate. The SANE is to make the patient comfortable and to NOT push conversation if not wanted
A nurse is providing discharge teaching to a patient who has been prescribed buspirone for generalized anxiety disorder. Which statement by the patient indicates a need for further teaching?
A) "I understand this medication will take 2 to 4 weeks before I feel the full effects."
B) "I can stop taking this medication once my anxiety symptoms improve since it doesn't cause dependence."
C) "I should take this medication regularly, not just when I feel anxious."
D) "I may experience dizziness and headaches, so I'll be careful when driving at first."
B
This med takes 2-4 weeks and does not cause dependence however does need to be taken on a regular basis
Mary Ann is a 74 year old female with a long history of schizophrenia. She was recently prescribed haloperidol decanoate. What teaching needs be stressed when discussing everyday activities?
Do not drive
Do not drink
Do wear sun screen
Do take every morning
Wearing sunscreen
A nurse is teaching a group of nursing students about stress-reduction techniques. A student asks, "Which relaxation technique is most commonly used in the United States?" Which response by the nurse is correct?
A) Progressive muscle relaxation
B) Deep-breathing exercises
C) Guided imagery
D) Meditation
B
A 10-year-old patient with oppositional defiant disorder becomes increasingly agitated on the pediatric psychiatric unit, yelling at staff and throwing objects. The nurse has attempted verbal de-escalation without success. The patient continues to escalate and poses a risk to others. Which action should the nurse take next according to the principle of least restrictive intervention?
A) Immediately place the patient in physical restraints to prevent injury
B) Offer PRN medication to help the patient regain control
C) Call a psychiatric emergency code to have the team respond
D) Place the patient in seclusion until the behavior stops
B
Verbal > Offer meds > seclusion > restraint
A nurse is caring for a 32-year-old patient on an inpatient psychiatric unit who is becoming increasingly agitated, pacing rapidly, speaking loudly, and clenching fists. The nurse has attempted verbal de-escalation without success. The healthcare provider orders medication to prevent an aggressive incident. Which medication combination would be most appropriate for acute agitation management?
A) Fluoxetine 20 mg and diphenhydramine 25 mg PO
B) Haloperidol 5 mg IM and lorazepam 2 mg IM
C) Lithium 300 mg PO and clonidine 0.1 mg PO
D) Aripiprazole 10 mg PO once daily
B
IM will act the quickest to mitigate the threat of violence. The medications of choice in an acutely agitated patient are benzodiazepines and antipsychotics
Sophia was recently put on phenelzine, an MAOI, and you are teaching her about dietary guidelines for this medication. Which of the following shows the Sophia has been adequately educated about phenelzine?
A). Since I have been off of sertraline for the past week it is safe for me to start taking this in 3 days.
B). I can take this medication with my methylphenidate.
C). I need to stop drinking caffeine and tea as well as reduce my intake of cheese.
D). I can take nasal decongestants such as pseudoephedrine (Sudafed) with this medication.
C
all of the mentioned foods have tyramine in them, which can cause a hypertensive crisis in a patient taking MAOIs; it takes 2 weeks between taking antidepressants before taking an MAOI due to the risk of serotonin syndrome, especially in an SSRI such as sertraline; stimulants should be avoided d/t in the increased risk of hypertensive crisis
A nurse is caring for a patient with schizophrenia who suddenly stops mid-conversation, turns their head to the side, and appears to be listening to something. The patient's lips are moving silently, and they begin to look frightened. Which nursing response is most therapeutic?
A) "There is no one talking to you. You need to focus on our conversation."
B) "I notice you seem distracted and frightened. I don't hear any voices, but I understand this is real to you. You're safe here with me."
C) "Tell me what the voices are saying so I can help you understand they aren't real."
D) "Let me turn on some music to help you stop hearing those voices."
I notice you seem distracted and frightened. I don't hear any voices, but I understand this is real to you. You're safe here with me.
A nurse is providing health teaching to a patient newly diagnosed with generalized anxiety disorder. The patient asks, "What can I do at home when I start feeling anxious?" Which response demonstrates the nurse's understanding of anxiety management?
A) "Try to distract yourself by watching television until the anxiety passes."
B) "Practice relaxation exercises like deep breathing to activate your relaxation response and reduce your heart rate."
C) "Avoid situations that make you anxious until your medication starts working."
D) "Call your healthcare provider immediately whenever you feel anxious."
Option B is correct because:
A nurse is conducting an intake assessment for a 28-year-old patient in an outpatient mental health clinic. The patient arrives wearing multiple religious symbols from different faiths and explains, "I can sense when bad energy is around me, and yesterday my neighbor got sick because I accidentally thought negative thoughts about him." During the conversation, the patient provides long, abstract explanations that are difficult to follow and frequently glances around the room suspiciously. The patient states, "I don't have friends because people are always plotting against me." Which personality disorder should the nurse suspect?
A) Schizoid personality disorder
B) Schizotypal personality disorder
C) Paranoid personality disorder
D) Borderline personality disorder
B
magical thinking, paranoia, social isolation, severe social deficits
A nurse in the emergency department is caring for a 35-year-old patient who was brought in by family after losing their job and home in the same week. The patient states, "I can't handle this anymore. Nothing I try works. I don't know what to do." The patient appears tearful and is wringing their hands. Which nursing response best demonstrates crisis intervention principles?
A) "You need to stay calm. Let me tell you exactly what steps you should take to fix these problems."
B) "I think you should speak with a social worker about long-term counseling for your issues."
C) "Many people lose their jobs. You'll feel better once you have time to process this situation."
D) "I can see this is overwhelming for you right now. Let's talk about what's happening and explore some options together."
D
"you need to stay calm" is nontherapeutic
B does not empower someone to take control themselves
Minimization is nontherapeutic
A patient receiving lithium needs regular blood tests for these 3 main reasons.
Lithium levels
Renal impairment- can cause toxicity
Can worsen hypothyroidism
A nursing student is learning about the mechanism of action for benzodiazepines in treating anxiety disorders. The student asks the clinical instructor, "How do benzodiazepines reduce anxiety symptoms?" Which response by the instructor is most accurate?
A) "Benzodiazepines increase serotonin availability in the synapse, which takes 4-6 weeks to reduce anxiety."
B) "Benzodiazepines enhance GABA activity by increasing the frequency of chloride channel opening, causing a calming effect."
C) "Benzodiazepines block dopamine receptors in the limbic system, preventing excessive neuronal excitation."
D) "Benzodiazepines inhibit norepinephrine reuptake, which decreases the physiological symptoms of anxiety."
Benzodiazepines enhance GABA activity by increasing the frequency of chloride channel opening, causing a calming effect.
You are educating a nursing student on intentional medication overdoses. You discuss a patient who has a significant history of intentional medication overdose. You ask the student what type of antidepressant is safest for the patient. Which of the following shows adequate knowledge?
A. Tricyclic antidepressants because they do not affect the cardiac system like atypical antidepressants do.
B. MAOIs because they have a less chance of hypertension than TCAs
C. Atypical antidepressants because they have a lesser chance of causing serotonin syndrome than MAOIs and SSRIs
D. SSRIs because there is a higher dose needed to reach lethal amounts
C
TCA cause cardiotoxicity and CNS depression
SSRI cause serotonin syndrome
SNRI cause serotonin syndrome and increase cardiac workload d/t norepinephrine
MAOI cause hypertensive crises and death
Sarah is a 54 year old female who has a history of substance use disorder, sexual coercion, and has been arrested multiple times for DUI and cannot maintain a stable job. When you refuse to let her use the phone after 8 p.m. she says, "But Sam let me yesterday." What should be documented and communicated during shift change?
Sarah has manipulative behaviors and attempts to pit staff against each other.
A nurse is conducting an assessment of a 9-year-old child brought to the clinic by a foster parent. The child was removed from their home 3 months ago due to chronic neglect and witnessed domestic violence. During the assessment, the child becomes suddenly withdrawn when asked about school, begins rocking back and forth, and stops making eye contact. The child's heart rate increases from 82 to 118 bpm. Which nursing action demonstrates the best understanding of trauma-informed care?
A) Continue the assessment questions to gather complete information for the treatment plan, as a comprehensive clinical interview assessing all symptoms is required for PTSD diagnosis
B) Recognize the child is in a hypoarousal state and implement strategies to increase engagement and prevent further withdrawal
C) Recognize the child has moved outside their window of tolerance into hyperarousal and help them return to a regulated state before continuing
D) Immediately refer the child to an advanced practice psychiatric nurse for Eye Movement Desensitization and Reprocessing (EMDR) therapy
C
Ignoring the patient is not trauma informed
The patient is in hypER not hypOarrousal
Although EMDR is the first line treatment for trauma, an immediate referral is not indicated
A nurse is caring for a 28-year-old patient with schizophrenia who has been taking quetiapine (Seroquel) 400 mg twice daily for 6 months. During a routine follow-up visit, the patient reports increased thirst, frequent urination, and a 15-pound weight gain concentrated around the abdomen. Laboratory results show: fasting blood glucose 142 mg/dL, HbA1c 6.8%, triglycerides 220 mg/dL, HDL 35 mg/dL. The patient states, "I feel better mentally, but I'm worried about these changes." Which nursing response demonstrates the best understanding of second-generation antipsychotic management?
A) Reassure the patient these are temporary side effects that will resolve with continued use and encourage adherence to prevent relapse
B) Recognize signs of metabolic syndrome, notify the healthcare provider, and discuss the importance of monitoring while exploring the patient's concerns
C) Immediately discontinue the quetiapine to prevent progression to diabetes and request an order for a first-generation antipsychotic
D) Explain that weight gain indicates the medication is working effectively and recommend over-the-counter diet supplements
B
metabolic syndrome is not a temporary side effect of 2nd generations; abrupt d/c can cause severe side effects; weight gain is a side effect not a therapeutic indicator