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NURSING 4241
MENTAL HEALTH CONDITIONS
EXAM Q & A
1. A 25-year-old woman is admitted to the psychiatric unit with a diagnosis
of bipolar disorder, manic episode. She is restless, talkative, and has
grandiose ideas. She tells the nurse that she is a famous singer and she has a
concert tonight. The nurse should:
a) Agree with her and ask her to sing a song
b) Confront her with reality and tell her that she is not a singer
c) Ignore her statements and redirect her to another topic
d) Acknowledge her feelings and set limits on her behavior*
Rationale: The nurse should acknowledge the patient's feelings and set
limits on her behavior to prevent further escalation of mania and ensure
safety. Agreeing with her delusions or confronting her with reality may
increase her agitation and anxiety. Ignoring her statements may make her
feel rejected and isolated.
2. A 45-year-old man is brought to the emergency department by his wife,
who says he has been depressed and suicidal for the past two weeks. He
tells the nurse that he has a plan to kill himself by overdosing on his
antidepressants. He says he has no hope for the future and he feels
worthless and guilty. The nurse should:
a) Explore his suicidal plan and assess his level of risk*
b) Reassure him that everything will be okay and he has a lot to live for
c) Leave him alone in a quiet room to calm down
d) Give him a list of crisis hotline numbers and community resources
Rationale: The nurse should explore his suicidal plan and assess his level of
risk to determine the urgency of the situation and intervene accordingly.
Reassuring him or giving him a list of resources may not be helpful if he is
not ready to accept help or change his mind. Leaving him alone may
increase his chance of harming himself.
3. A 35-year-old woman is diagnosed with post-traumatic stress disorder
(PTSD) after being sexually assaulted by a stranger. She has nightmares,
flashbacks, and avoids places that remind her of the trauma. She is referred
to a cognitive-behavioral therapist, who suggests that she should try
exposure therapy. Exposure therapy is:
a) A technique that involves repeated exposure to the traumatic event in a
safe and controlled environment*
b) A technique that involves relaxation training and positive imagery
c) A technique that involves challenging irrational thoughts and beliefs
related to the trauma
d) A technique that involves expressing emotions and feelings through art
or music
Rationale: Exposure therapy is a cognitive-behavioral technique that
involves repeated exposure to the traumatic event in a safe and controlled
environment, such as imaginal, virtual, or in vivo exposure. The goal is to
reduce fear and anxiety by habituation and extinction of conditioned
responses. Relaxation training, positive imagery, cognitive restructuring, and
expressive therapies are other techniques that may be used for PTSD, but
they are not exposure therapy.
B:
1. Which assessment finding is most indicative of a patient experiencing a
major depressive episode?
a) Inflated self-esteem or grandiosity
b) Flight of ideas or racing thoughts
c) Insomnia or hypersomnia
d) Psychomotor agitation or retardation
Answer: c) Insomnia or hypersomnia
Rationale: Insomnia or hypersomnia (sleep disturbances) is commonly seen
in individuals with major depressive episode.
2. The nurse is preparing to administer a medication for a patient with
bipolar disorder. Which medication should the nurse expect to administer?
a) Sertraline
b) Lithium
c) Diazepam
d) Quetiapine
Answer: b) Lithium
Rationale: Lithium is a mood stabilizing medication commonly used to
manage bipolar disorder.
Answer: a) Establishing a safety plan for the patient
Rationale: The nurse's priority is to ensure patient safety and prevent self-
harm. Establishing a safety plan is crucial to manage and minimize self-
harming behaviors.
7. The nurse is assessing a patient for symptoms of alcohol withdrawal.
Which is the most severe symptom that may lead to life-threatening
complications?
a) Tremors and restlessness
b) Diaphoresis and anxiety
c) Hallucinations and delirium tremens
d) Nausea and vomiting
Answer: c) Hallucinations and delirium tremens
Rationale: Hallucinations and delirium tremens are severe symptoms of
alcohol withdrawal that may lead to life-threatening complications, such as
seizures or cardiovascular instability.
8. A patient with attention deficit hyperactivity disorder (ADHD) is
prescribed methylphenidate (Ritalin). The nurse educates the patient and
family about the medication. Which statement by the patient's mother
requires clarification?
a) "I should administer the medication in the morning."
b) "It is important to monitor the patient's blood pressure regularly."
c) "Methylphenidate can help improve attention span and decrease
impulsivity."
d) "I should discontinue the medication if my child experiences irritability
or mood swings."
Answer: d) "I should discontinue the medication if my child experiences
irritability or mood swings."
Rationale: Methylphenidate, a common medication used for ADHD, can
cause irritability or mood swings as side effects. It is essential to educate the
patient's mother that these side effects should be reported but not
necessarily result in discontinuation.
9. A patient with schizophrenia is prescribed haloperidol (Haldol). What is
the nurse's primary responsibility before administering this medication?
a) Assessing the patient's liver function
b) Assessing the patient's blood glucose level
c) Assessing the patient's blood pressure
d) Assessing the patient's white blood cell count
Answer: c) Assessing the patient's blood pressure
Rationale: Haloperidol can cause orthostatic hypotension as a side effect.
Therefore, the nurse must assess the patient's blood pressure and ensure it
is stable before administering the medication.
10. A patient with obsessive-compulsive disorder (OCD) is prescribed
selective serotonin reuptake inhibitors (SSRIs). What should the nurse
include in the patient's medication education?
a) "You may experience immediate relief from your obsessive thoughts."
b) "It may take several weeks before you notice a decrease in symptoms."
c) "You should avoid exposure to sunlight during medication use."
d) "You should discontinue the medication if you experience any
gastrointestinal side effects."
Answer: b) "It may take several weeks before you notice a decrease in
symptoms."
Rationale: SSRIs, commonly used for OCD treatment, require several weeks
for the full therapeutic effect. Patients should be educated that
improvement in symptoms may not occur immediately.
11. The nurse is conducting a mental status examination on a patient with
suspected dementia. Which question is most appropriate to assess the
patient's orientation?
a) "What is your name?"
b) "What is today's date?"
c) "Can you recall the names of your children?"
d) "What did you have for breakfast?"
Answer: b) "What is today's date?"
Rationale: Assessing the patient's knowledge of the current date helps
determine the level of orientation and can indicate cognitive impairment
associated with dementia.
12. The nurse is caring for a patient admitted with a manic episode. Which
intervention is most important to promote a safe and therapeutic
environment?
a) Encouraging social interactions with other patients
b) Setting strict boundaries and rules
c) Encouraging physical activity during the day
d) Limiting communication with family and friends
Answer: b) Setting strict boundaries and rules
Rationale: During a manic episode, setting strict boundaries and rules is
C:
1. A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, No one cares about me anymore. Im not worth anything. Select an appropriate initial outcome for the nursing diagnosis: Situational low self- esteem, related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. consent to take antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date). 2. A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. You look nice this morning. b. You are wearing a new shirt. c. I like the shirt youre wearing. d. You must be feeling better today. 3. An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques 4. A priority nursing intervention for a patient diagnosed with major depressive disorder is: a. distracting the patient from self-absorption. b. carefully and inconspicuously observing the patient around the clock. c. allowing the patient to spend long periods alone in self-reflection. d. offering opportunities for the patient to assume a leadership role in the therapeutic milieu. 5. When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies. 6. A patient says to the nurse, My life does not have any happiness in it anymore. I once enjoyed holidays, but now theyre just another day. How would the nurse document the complaint? a. Vegetative symptom b. Anhedonia c. Euphoria d. Anergia
7. A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, I dont think I can keep taking these pills. They make me so, especially when I stand up. The nurse should: a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. teach the patient how to use pursed-lip breathing. 8. A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention 9. A patient diagnosed with major depressive disorder tells the nurse, Bad things that happen are always my fault. To assist the patient in reframing this overgeneralization, the nurse should respond: a. I really doubt that one person can be blamed for all the bad things that happen. b. Lets look at one bad thing that happened to see if another explanation exists. c. You are being exceptionally hard on yourself when you say those things. d. How does your belief in fate relate to your cultural heritage? 10. A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration. 11. A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet. 12. A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls 13. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Monitoring pupillary responses d. Assisting the patient to identify and test negative thoughts 14. A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting.
c. Hot tea d. Milk
22. During a psychiatric assessment, the nurse observes a patients facial expressions that are without emotion. The patient says, Life feels so hopeless to me. Ive been feeling sad for several months. How should the nurse document the patients affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent 23. A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, You must bathe daily. d. firmly and neutrally assist the patient with showering. 24. A patient was started on escitalopram (Lexapro) 5 days ago and now says, This medicine isnt working. The nurses best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief. 25. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward 26. A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient himself or herself to a pressured work schedule. 27. A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock. 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 mood
A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident A 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 management A 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?" 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. 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. 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) 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. The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's 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
the nurse's 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. 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 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 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 coping Which 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 cream Outcome 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. 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 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 changes A 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 nurse's best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's 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. 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. 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, "I'll throw the pool balls if anyone comes near me." The nurse's 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. After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation 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 edema A 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 nurse's 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. "It's unusual that the health care provider has not already stopped your medication." A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've 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." Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure
a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) 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 nurse's 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." 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 security A patient diagnosed with schizophrenia has catatonia. The patient is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's 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. 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 withdrawal Which 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 prescribed A 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 nutrition A 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 nurse's 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 patient's arm; leave if the patient does not respond
within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports. 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. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's 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." 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. Akathisia A 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 patient's 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. Akathisia An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's 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 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 patient's 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 effects 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 behavior
c. thought insertion. d. an idea of reference. 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 patient's shoulders. c. place a hand on the patient's arm and exert light pressure. 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 nurse's 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?" 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 nurse's 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. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5'2' 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 measures A 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 agitation An older adult takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, this adult developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer disease. A patient experiencing fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance
A patient experiencing fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry. I will have someone stay here and brush off the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you." What is the priority nursing diagnosis for a patient experiencing fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints Which environmental adjustment should the nurse make for a patient experiencing delirium with perceptual alterations? a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly, day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation. Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken. Consider these health problems: Lewy body disease, Pick disease, and Korsakoff syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia When used for treatment of patients diagnosed with Alzheimer disease, which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne) An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia
