1
A patient diagnosed with paranoid schizophrenia tells the nurse that, “Dr. Smith has killed several other patients, and now he is trying to kill me.” What is the best response?
1. “I have worked here a long time. No one has died. You are safe here.”
2. “What has Dr. Smith done to make you think he would like to kill you?”
3. “All of the staff, including Dr. Smith, are here to ensure your safety.”
4. “Whenever you are concerned or nervous, talk to me or any of the nurses.”
Ans: 4
The nurse can acknowledge the patient's fears without agreeing or disagreeing with his accusation toward Dr. Smith. Directing him to talk to the nursing staff provides a source of emotional support and an action that he can use to decrease his anxiety. Telling the patient that no one has died and that the staff will ensure safety is presenting reality; however, he believes that someone has been killed and that Dr. Smith is responsible, so this opens opportunities for an argument. Asking him to explain his rationale for his beliefs encourages him to elaborate on his delusion.
On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?
1. Fearfulness regarding treatment measures
2. Anger and aggressiveness directed toward others
3. An understanding of the pathology and symptoms of the diagnosis
4. A willingness to participate in the planning of the care and treatment plan
Answer: 4
Rationale: In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since she or he is actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands her or his mental health problem, only the client’s desire for help.
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate nutrition
Answer: 1
Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client- centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.
Test-Taking Strategy: Use therapeutic communication techniques. First eliminate options that do not support the client’s expression of feelings. Any option that is not client-centered should be eliminated next. Focusing on the client’s feelings will direct you to the correct option.
A well-known celebrity is admitted to the psychiatric unit. Several RNs from other units drop by and express an interest in seeing the patient. What is the best response?
1. “Please be discreet and do not interrupt the work flow.”
2. “How did you find out that the patient was admitted to this unit?”
3. “Please wait. I need to call the nursing supervisor about this request.”
4. “I’m sorry; the patient has asked that only family be allowed to visit.”
Ans: 2
First try to determine how the nurses found out about the patient's admission. This is a serious Health Insurance Portability and Accountability Act (HIPAA) violation, and information disclosure must be immediately stopped. Unfortunately for these RNs, administration will have to be notified, but as a professional courtesy, it would be better if they went directly to the supervisor and admitted the error rather than immediately calling the supervisor and reporting them.
A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action should the nurse take initially?
1. Contact the client’s health care provider (HCP).
2. Call the client’s family to arrange for transportation.
3. Attempt to persuade the client to stay “for only a few more days.”
4. Tell the client that leaving would likely result in an involuntary commitment.
Answer: 1
Rationale: In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release, unless they pose an immediate danger to themselves or others, in which case the admission could become involuntary depending on the circumstances and regulations in that area and facility. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client’s permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying “for only a few more days” has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client’s condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.
Test-Taking Strategy: Note the strategic word, initially. Noting the type of hospital admission will assist in directing you to the correct option while eliminating those that are unlikely to occur. Calling the family should be eliminated, based on the issues of client rights and confidentiality. To “persuade” a client to stay in the hospital is inappropriate. Threatening the client is inappropriate and illegal.
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?
1. A crisis state indicates that the client has a mental illness.
2. A crisis state indicates that the client has an emotional illness.
3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis.
4. A client’s response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
Answer: 4
Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client, because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.
Test-Taking Strategy: Eliminate option 3 because of the closed-ended word “all.” Next, eliminate options 1 and 2, because a crisis does not indicate “illness.”
The nurse is working at a community clinic that specializes in assisting patients who need medication and therapy for mental health disorders. Which patient is the most likely candidate for depot antipsychotic therapy?
1. Older man with psychosis secondary to dementia who lives with his daughter
2. Homeless veteran with schizophrenia who occasional sleeps in a nearby shelter
3. Housewife with bipolar disorder who is prone to psychotic features during the manic phase
4. Student with recently diagnosed schizophrenia who lives at home with his parents
Ans: 2 Depot antipsychotic therapy uses long-acting injectable medications. These medications are used for long-term maintenance for schizophrenia for patients who may have some difficulties with adherence to taking medications. The homeless veteran has the least amount of social support and stability, which are factors in medication adherence. For the older adult patient with dementia and psychosis, identifying underlying factors and then behavioral therapies would be recommended first. Psychotic features in the manic phase of bipolar disorder would be treated as an acute episode. The student has the support of family, and the health care team will try to work with the patient and the family to build behaviors that support lifetime adherence to therapy. Focus: Prioritization.
A nursing student reports to the nurse that he has observed several types of behavior among the patients. Which patient needs priority assessment?
1. A patient who is having command hallucinations
2. A patient who is demonstrating clang associations
3. A patient who is verbalizing ideas of reference
4. A patient who is using neologisms
Ans: 1 Assess the content of command hallucinations because the patient may be getting a command to harm self or others. Ideas of reference occur when an ordinary thing or event (e.g., a song on the radio) has personal significance (e.g., belief that the lyrics were written for him or her). Ideas of reference could escalate into aggression, especially if delusions of persecution are present, so the nurse would check on this patient next. Clang association is a meaningless rhyming of words, and neologisms are new words created by patients. These communication patterns create frustration for staff and patients, but there is no need for immediate intervention.
Test Taking Tip: Safety is a priority concern for all patients. In identifying safety issues for patients with active psychosis, the potential concern is frequently harm to self or to others.
A depressed client on an inpatient unit says to the nurse, “My family would be better off without me.” Which is the nurse’s best response?
1. “Have you talked to your family about this?”
2. “Everyone feels this way when they are depressed.”
3. “You will feel better once your medication begins to work.”
4. “You sound very upset. Are you thinking of hurting yourself?”
Answer: 4
Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client’s feelings.
Test-Taking Strategy: Note the strategic word, best. Recalling therapeutic communication techniques will assist in directing you to the correct option. Option 4 is the only option that deals directly with the client’s feelings. In addition, clients at risk for suicide need to be assessed directly regarding the potential for self-harm.
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
1. “You need to stop that behavior now.”
2. “You will need to be placed in seclusion.”
3. “You seem restless; tell me what is happening.”
4. “You will need to be restrained if you do not change your behavior."
Answer: 3
Rationale: The most appropriate statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate option 1 because of the demand that it places on the client. Eliminate options 2 and 4 because they indicate threats to the client.
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
1. “My medications will help my anxious feelings.”
2. “I’ll go to support group and talk about what I am feeling.”
3. “When I have command hallucinations, I’ll call a friend for help.”
4. “I need to get enough sleep and eat well to help prevent feeling anxious.”
Answer: 3
Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt herself or himself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.
Test-Taking Strategy: Note the strategic words, need for additional information. These words indicate a negative event query and the need to select the incorrect statement as the answer. Focus on the subject, managing hallucinations and anxiety. The correct option is a specific agreement to seek appropriate help. The remaining options are interventions that a client can carry out to aid wellness.
A patient comes into the walk-in clinic and tells the nurse that he would like to be admitted to an alcohol rehabilitation program. Which question is the most important to ask?
1. “What made you decide to enter a program at this time?”
2. “How much alcohol do you usually consume in a day?”
3. “When was the last time you had a drink?”
4. “Have you been in a rehabilitation program before?”
Ans: 3 Before someone enters an alcohol rehabilitation program, there should be a medically supervised detoxification. This patient has walked in off the street; therefore, the nurse must determine whether he is at risk for withdrawal symptoms. Withdrawal from alcohol can be life threatening. The other questions are relevant and are likely to be included in the interview.
Primary prevention of domestic abuse involves:
1. Conducting community classes to teach parents about normal developmental challenges.
2. Early intervention to prevent or stop the violence.
3. Identification of families at risk for violence.
4. Strengthening individuals and families to enable them to better cope with life stressors.
Answer: 4.
Primary prevention of abuse involves strengthening individuals and families to enable them to better cope with multiple life stressors. For example, nurses can conduct community classes to teach parents about normal developmental challenges, such as toilet training; ways to discipline without physical punishment; and methods of conflict resolution. Secondary prevention involves identification of families at risk for violence and those who are beginning to use violence, followed by early intervention to prevent or stop the violence.
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication?
1. Platelet count
2. Blood glucose level
3. Liver function studies
4. White blood cell count
Answer: 4
Rationale: A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.
Test-Taking Strategy: Focus on the subject, complications associated with clozapine. It is necessary to recall that this medication causes agranulocytosis; this will direct you to the correct option.
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level?
1. Toxic
2. Normal
3. Slightly above normal
4. Excessively below normal
Answer: 1
Rationale: Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Symptoms of toxicity begin to appear at levels of 1.5 mEq/L (1.5 mmol/L). Lithium toxicity requires immediate medical attention and the primary health care provider is notified if symptoms of toxicity occur.
Test-Taking Strategy: Focus on the subject, therapeutic serum medication level of lithium. Recalling that the high end of the maintenance level is 1.2 mEq/L (1.2 mmol/L) will direct you to the correct option.
Which assessment data indicates quetiapine is effective for the client diagnosed with paranoid schizophrenia?
1. The client does not exhibit any tremors or rigidity.
2. The client reports a 2 on an anxiety scale of 1–10
3. The family reports the client is sleeping all night.
4. The client denies having auditory hallucinations.
ANS: 4
Antipsychotic medications are prescribed to decrease the signs or symptoms of schizophrenia. If the client denies auditory hallucinations, then the atypical antipsychotic quetiapine (Seroquel) medication is effective.
1. Tremors or rigidity indicate the client is having extrapyramidal side effects of antipsychotic medications. Such activity does not indicate the medication is effective.
2. Antipsychotic medications are not prescribed for anxiety; therefore, anxiety cannot be evaluated to determine if the medication is effective.
3. Sleeping all night is a good sign for the client, but it does not determine if the medication is effective.
Which questionnaire should the nurse use to screen a male client for alcohol abuse?
1. CAGE.
2. COPE.
3. FACT.
4. TACE.
Answer: 1.
The CAGE questionnaire is used to screen a client for alcohol abuse. There is no such thing as the COPE questionnaire. There is no such thing as the FACT questionnaire. TACE is a 4-item questionnaire based on CAGE but for use with pregnant women.
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?
1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with simple open-ended questions.
4. Take the client into the dayroom with other clients to provide stimulation.
Answer: 3
Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client’s safety is not the responsibility of other clients.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate options either that are nontherapeutic or could result in overstimulation. Also eliminate options that are not examples of therapeutic communication. The correct option provides for client supervision and communication as appropriate.
The patient tells the nurse that he drinks 3 or 4 servings of alcohol every day. He also reports frequently taking acetaminophen for stress-related headaches. Based on this information, which laboratory test results are the most important to follow up on?
1. Renal function tests
2. Liver function tests
3. Cardiac enzymes
4. Serum electrolytes
Ans: 2
Regular, even moderate, consumption of alcohol and excessive use of acetaminophen (maximum dose is 4000 mg/day) can cause fatal liver damage. Some authorities recommend that people who drink moderately should limit the total daily dose of acetaminophen to 2 g/day.
A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He has been prescribed haloperidol. What is the priority action by the nurse?
1. Maintain eye contact and stay with him until the spasms pass.
2. Place the patient on aspiration precautions until the spasms subside.
3. Obtain an order for intramuscular or IV diphenhydramine.
4. Obtain an order for and administer an antiseizure medication.
Ans: 3
IV administration of diphenhydramine will rapidly alleviate the symptoms. The patient is experiencing medication side effects. This condition is frightening and uncomfortable for the patient, but it is not usually harmful. Swallow precautions will not harm the patient, but waiting for the spasms to pass delays the most appropriate intervention.
The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client.
1. Get adequate sunlight.
2. Continue driving as usual.
3. Avoid foods rich in potassium.
4. Get up slowly when changing positions.
ANS: 4
Rationale: Risperidone can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. With any psychotropic medication, caution needs to be taken (such as with driving or other activities requiring alertness) until the individual can determine whether her or his level of alertness is affected. Food interaction is not a concern.
A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication?
1. Constipation
2. Seizure activity
3. Increased weight
4. Dizziness when getting upright
Answer: 2
Rationale: Seizure activity can occur in clients taking bupropion dosages greater than 450 mg daily. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. This medication does not cause significant orthostatic blood pressure changes.
The client diagnosed with depression is prescribed phenelzine. Which statement by the client indicates to the nurse the medication teaching is effective?
1. “I am taking the herb ginseng to help my attention span.”
2. “I drink extra fluids, especially coffee and iced tea.
3. “I am eating three well-balanced meals a day.”
4. “At a family cookout I had chicken instead of a hot dog.”
ANS: 4
Taking phenelzine (Nardil), a monoamine oxidase (MAO) inhibitor, requires adherence to strict dietary restrictions concerning tyramine-containing foods, such as processed meat (hot dogs, bologna, and salami), yeast products, beer, and red wines. Eating these foods can cause a life-threatening hypertensive crisis.
Which client would it be most appropriate to prescribe disulfiram?
1. A client diagnosed with chronic alcoholism admitted to the medical unit.
2. A highly motivated client who wants to quit drinking alcohol.
3. A client who has been taking amphetamines for more than 1 year.
4. A highly motivated client who wants to quit taking heroin.
ANS: 2
Disulfiram (Antabuse), an abstinence medication, is only effective in highly motivated clients because the success of pharmacotherapy is entirely dependent on client compliance. This client is highly motivated to quit drinking alcohol.
Which adverse reaction can be attributed to a medication in the classification of tricyclic anti- depressants?
1. Increased temperature.
2. Miosis.
3. Hypersecretions.
4. Pallor.
Answer: 1.
Hyperthermia is one of the anticholinergic effects that can take place as either an adverse reaction or an overdose situation. Anticholinergic effects include mydriasis, flushed skin, dry mucous membranes, anxiety, psychoses, tachycardia, hyperthermia, and urinary retention. A mnemonic that is helpful in remembering the anticholinergic effects of tricyclic reaction or overdose is: Blind as a Bat, Red as a Beet, Dry as a Bone, Mad as a Hatter, and Hotter than Hades. Miosis, hypesecretions, and pallor are not manifestations of tricyclic antidepressants.